No, I’m not talking about putting fentanyl into my own veins — a remarkably bad idea. I’m questioning the habitual, reflex use of fentanyl, a synthetic opioid, in clinical anesthesiology practice.

I’ve been teaching clinical anesthesiology, supervising residents and medical students, in the operating rooms of academic hospitals for the past 18 years. Anesthesiology residents often ask if I “like” fentanyl, wanting to know if we’ll plan to use it in an upcoming case. My response always is, “I don’t have emotional relationships with drugs. They are tools in our toolbox, to be used as appropriate.”

But I will say that my enthusiasm for using fentanyl in the operating room, as a component of routine, non-cardiac anesthesia, has rapidly waned. In fact, I think it has been months since I’ve given a patient fentanyl at all.

Here’s why.

What is fentanyl?

Fentanyl is an opioid pain-killer in the same class as morphine or Demerol, meaning that it acts on the same receptors in the brain to lessen the subjective experience of pain. It appeared on the market in 1960, and quickly gained wide use in anesthesia practice.

Fentanyl is potent and works fast, which makes it very effective in treating the intense stimulus of surgical pain, and its peak effect lasts only a short time. It’s also inexpensive, which makes it attractive in an era of cost containment in healthcare.

When I started my anesthesia residency, we assumed that since fentanyl’s analgesic and euphoric effects were so brief, short-term exposure to the drug wouldn’t increase a patient’s risk of long-term narcotic abuse. For the first few years, fentanyl was kept in unsecured medication carts in the operating rooms along with Benadryl, lidocaine, and other commonly used medications.

But anesthesiology departments quickly learned that fentanyl did indeed have high abuse potential. Its pleasurable “high” and rapid onset proved irresistible to some people, and deaths from overdose occurred all too often among medical personnel. Now, we track every microgram of fentanyl used or discarded during surgery.

Fentanyl stayed quietly under the radar for decades as an IV drug useful primarily in anesthesiology practice. But it began to see more use in the treatment of chronic pain — as transdermal patches, or “lollipops” for absorption by mouth. And with its increased availability came a higher risk of abuse. The well-publicized death of the musician Prince in 2016 from an accidental overdose propelled fentanyl into fame.

Today fentanyl is making headlines as the drug responsible for an ever-increasing number of opioid overdose deaths. Cheap to synthesize, it’s being laced into heroin and illegally made into pills that look just like oxycodone. People don’t have any way of knowing how much they are taking, and they die because they stop breathing.

Of course, illegal fentanyl abuse is the polar opposite of administering fentanyl responsibly as a licensed anesthesia professional who is monitoring the patient’s every breath. But we’ve learned that opioids, even when legally and carefully administered with the best intentions, may have unintended consequences.

Pain relief can lead to more pain

The key fact, often poorly understood by physicians — let alone the general public — is that treating pain with opioids can lead to more pain, a phenomenon known as “opioid-induced hyperalgesia”.

This is different from tolerance to the pain-relieving effects of opioids. Most people understand that if you start taking any narcotic — whether morphine, oxycodone, or fentanyl — over time you will become “tolerant” to the drug’s effect and will need more of it to achieve the same level of pain relief.

Opioid-induced hyperalgesia, or “OIH”, is a different problem. The definition of hyperanalgesia is abnormally heightened sensitivity to pain. OIH is defined as hypersensitivity to pain that occurs as a result of opioid use. When surgical patients receive opioids while under anesthesia, several studies have demonstrated increased opioid requirements after surgery, and worse, not better, pain scores.

An excellent 2016 review article in the journal Anesthesiology pointed out that the potential onset of OIH “should be considered when opioids are administered” to patients under anesthesia. It may well be that short-acting opioids such as fentanyl are worse offenders in terms of provoking OIH than longer-acting ones, as OIH increases when pain relief wears off and opioid doses must be repeated.

Do we need to use opioids during anesthesia?

Actually, we don’t. That has been the most surprising fact I’ve learned in recent years, as I’ve modified my practice in light of America’s lethal opioid epidemic.

There’s little reason to use fentanyl to block the unconscious patient’s blood pressure and heart rate responses during surgery, or the discomfort of having a breathing tube inserted. Other non-opioid anesthesia medications can do that just as well, without the risk of OIH.

In fact, a recent editorial from UCLA suggested that we don’t need to give opioids during surgical anesthesia at all, and that we would be better off reserving them for postoperative pain control. We can use other techniques — inhaled anesthetics, regional nerve blocks, epidurals, non-opioid pain medications — in a multimodal approach to treating painful stimuli during and after surgery. We can change our public image from “the docs with good drugs” to “proactive healers of our national opioid addiction epidemic.”

In light of all this information, I’m not sure I want my anesthesia practice associated with the use of fentanyl at all. I may be paranoid, but I suspect it’s only a matter of time until some clever plaintiff’s attorney sues anesthesia providers, claiming that a patient’s addiction was spawned by a first exposure to fentanyl during surgery. Who needs that misery?

As Joseph Heller wrote in Catch 22, “Just because you’re paranoid doesn’t mean they aren’t after you.” Enough said.

2 COMMENTS

New information for this ID doc. Thanks. Pain and fever control with Tylenol or NSAIDS in infections is what we fight all the time as suppression of both gives patients relief and they don't seek care till late. Especially true in necrotizing soft tissue infections.

David Reeder MD

Nice article. As I learned more about OIH and read about some studies with intraop esmolol, I tried a new approach to intraop care in a community hospital not affiliated with an academic center; for example, for a series of lap chole procedures, I induced with an appropriate dose of midazolam, lidocaine, propofol and rocuronium and added to that a small bolus of esmolol followed by an esmolol infusion. No opioids. Appropriate reversal of NMB and an updated round of lidocaine. Extubation ...Read More

Read All 2 COMMENTS

(This post chronicles the recent Los Angeles visit of ASA President Jeff Plagenhoef, MD, and his Grand Rounds presentation at USC. It originally appeared on the website of the California Society of Anesthesiologists. Above, Surgeon General Jerome Adams, MD, MPH, left, with Dr. Plagenhoef.)

“Who kicked whom off the anesthesia care team?” asked ASA President Jeff Plagenhoef, MD, FASA. Which professional association refuses to work amicably with the other, he inquired of his audience at the University of Southern California on September 15, as he delivered a powerful Grand Rounds address to the Department of Anesthesiology.

In his talk, “Professional Citizenship:  Responsibilities Shared by All Anesthesiologists”, Dr. Plagenhoef emphasized that physician anesthesiologists and the American Society of Anesthesiologists (ASA) fully support nurse anesthesia practice within the physician-led anesthesia care team. In his practice as Chair of the Department of Anesthesiology at Baylor Scott and White Hillcrest Medical Center in Waco, Texas, Dr. Plagenhoef works with nurse anesthetists and with certified anesthesiologist assistants (CAAs).

Read the Full Article

3 COMMENTS

Domenica

You should look into hiring Certified Anesthesiologist Assistants if you are looking to continue the Anesthesia Care Team Model. As the article states, CAAs have a two year Masters degree in anesthesia education which requires an MCAT to enter. In addition, CAAs take a recertification exam every 6 years. All CAA legislation requires an Anesthesiologist-led Care Team model and the American Academy of Anesthesiologist Assistants fully supports the Anesthesia Care Team and the ASA.

Lacey

It's the opposite where I live. You would be hard pressed to find a CRNA in any of our local hospitals. The surgeons don't want them.

Read All 3 COMMENTS

The Practical Art of POCUS

The longer you practice a profession, the easier it is not to bother to learn the next new thing. We may think we’re doing just fine without that new drug, or that new piece of expensive equipment. We’ve seen how the new drug sometimes turns out to have more side effects than benefits, and how the equipment may gather dust in the corner because no one really needed it in the first place.

That isn’t going to happen with point-of-care ultrasound, or “POCUS”, I’m willing to bet. As I learned at a weekend conference on POCUS, jointly hosted by the anesthesiology departments at UCLA and Loma Linda University, the practical applications for bedside patient care are multiplying, and the technology is improving all the time. Ultrasound isn’t just for cardiologists and radiologists any more.

Read the Full Article

3 COMMENTS

Dr. Sibert, thank you very much for attending the workshop. Your post elegantly describes the overall message of what this course is focused on. It is my sincere hope that our specialty continues to embrace point of care ultrasound to improve our physical examination, as other acute care specialties have already done. Websites such as www.foresightultrasound.com and www.pocuseducation.com provide more educational material, as well as information for our course for next year. Again, thank you very much for your interest, and we hope ...Read More

Eduardo

(Errata sheet-Corrected version) Very interesting topic and right in point for me: I recently (last week) went to Buenos Aires, Argentina Anesthesia Annual Congress and this year much emphasize was done on ‘hands-on’practices and a lot in Ultrasound procedures and Regional Anesthesic US assisted. I can feel much anxiety and challenged by a shock of new skills that are abruptly for me, got in surface, even I’ve been good at the art of 'hand skills' and observation (can’t find proper slight adjectives for description). I got ...Read More

Read All 3 COMMENTS

Emory University held graduation ceremonies on August 5 for the 2017 Class of Anesthesiologist Assistants (AAs), who received Masters of Medical Science degrees. While the traditional academic regalia can’t fail to evoke Harry Potter in the minds of many of us, there is some magic in the processional and the music that always makes graduation a moving, meaningful event. I had the honor of delivering the commencement address, reprinted here.

Distinguished faculty, graduates, honored guests:

It is a great pleasure and an honor to be here, and to congratulate all the graduates of the Emory University Class of 2017 on your tremendous accomplishment. Just think about all you have learned in the past two years! You’ve transformed yourselves into real anesthesia professionals, able to deliver first-class care to patients at some of the most critical times in their lives.

Today is a great time to become an anesthesiologist assistant. Just two days ago, Dr. Jerome Adams was confirmed as our country’s Surgeon General. He is the first-ever physician anesthesiologist to have that honor. Even better, he is from Indiana, where he was the State Health Commissioner, and of course Indiana is among the states where CAAs are licensed to practice. We know that Dr. Adams understands the principles of the anesthesia care team. Dr. Adams gets it – who AAs are, what you do, and how well qualified you are to care for your patients.

Another happy thought – the Secretary of Health and Human Services today is Dr. Tom Price from Georgia, an orthopedic surgeon, and a former Representative in Congress. His wife, Betty, is a physician anesthesiologist who currently serves in the Georgia state legislature.

Whatever your opinions about politics (and believe me, we’re not going there today), whether your blood runs red or blue, I think we can all celebrate the fact that we now have people in key positions who understand anesthesia; whose presence in Washington is great for AAs, for patients, and for the practice of safe, team-based anesthesia care.

All About Great Medical Discoveries

As I thought about what to say to you today, the first thing that occurred to me is that this summer marks 30 years since I finished my anesthesia training. You might be curious to know if I ever had any second thoughts, any regrets about that career choice. My answer is a resounding “no”.

I was lucky enough to get interested in anesthesia at an early age. I brought something to show you. This book was published in 1960. It’s called All About Great Medical Discoveries, and I read it when I was a little girl about 8 or 9 years old, in Amarillo, Texas. Here’s what it had to say about anesthesia, in a chapter called “The Conquest of Pain”:

Read the Full Article

6 COMMENTS

David Denyer

that commencement speech was the best thing Ive read in a long time. Wisdom at every point! Thank you for all that you do for our profession and cant wait to work out there in California soon!

Gina Scarboro

Dr. Sibert, Thank you for the words of wisdom and encouragement for the Emory AA Program graduates. We appreciate your leadership and example of professional advocacy! Best, Gina Scarboro CAA

Read All 6 COMMENTS

The art of deep extubation

Fair warning — this post is likely to be of interest only to professionals who administer anesthesia or may have to deal with laryngospasm in emergency situations.

There are two schools of thought about how to extubate patients at the conclusion of general anesthesia:

Allow the patient to wake up with the endotracheal tube in place, gagging on the tube and flailing like a fish on a line, while someone behind the patient’s head bleats, “Open your eyes!  Take a deep breath!”

Or:

Remove the endotracheal tube while the patient is still sleeping peacefully, which results in the smooth emergence from anesthesia like waking from a nap.

It will not require much subtlety of perception to guess that I prefer option 2. It is quiet, elegant, and people who’ve seen it done properly often remark that they would prefer to wake from anesthesia that way, given the choice.

There is art and logic to it, which I had the pleasure of learning from British anesthesiologists at the Yale University School of Medicine years ago.

Read the Full Article

19 COMMENTS

Rahmat

Thank you for the article..I just succesfully extubated my patient with poorly controlled asthma by using this technique. A Very smooth emergence achieved.

Eduardo

Excellent topic of an usually underrated issue! Very useful for everyday practice. Thanks!

Read All 19 COMMENTS

X
¤