Opioid Anesthesiology4

Anesthesia Pharmacology Chapter 13: Opioid Pharmacology Advanced Topics

¹Influence of Opioids on Cardiovascular Dynamics

¹Hemodynamic responses to painful/noxious stimulation can be completely suppressed by the action of potent volatile anesthetics.
- The difficulty in this approach is that the amount of a volatile anesthetic needed to suppress such hemodynamic responses would also be sufficient to result in significant hypotension.
- Accordingly, opioids may be used to provide greater hemodynamic stability, suppressing hemodynamic responses to pain.
- The proposition that high-does opioids representing the primary/only anesthetic results in hemodynamic stability remains controversial.
  - Nevertheless, the role of opioids as an adjunct to other agents is well established as is the ability of opioids to suppress hemodynamic responses to events commonly occurring intraoperatively.
- Excursion from a stable hemodynamic profile can be associated with anesthesia induction, intubation, as well as events occurring during surgery. The qualitative and quantitative aspects of these excursions can be influenced by other factors which include:
  1. Extent of -adrenergic receptor blockade as well as the possibility of Ca²⁺ channel blockade
  2. Preoperative status of ventricular function
  3. Hydration state of the patient
  4. Administration of premedication
  5. Presence or absence of patient awareness.
- ¹The specific opioid used to modify hemodynamic excursions is also likely to have an effect.
  - This consideration is another example of lack of conclusive resolution in that some research indicates limited difference between fentanyl and sufentanil when used as principal anesthetics and cardiac surgery; whereas other results suggest that sufentanil might provide better intraoperative hemodynamic management.
  - Sufentanil administration appears to limit the need for vasodilators during cardiopulmonary bypass procedures as well as during the post-bypass period and the post-operative period.

"A comparison of morphine, fentanyl and sufentanil anesthesia for cardiac surgery: induction, emergence, and extubation"
An example of the comparative opioid study in the context of cardiac surgery; one that considers induction emergence and extubation is noted below in the work of Sanford et al. (1986). This study compared anesthetic doses of morphine (n = 10), fentanyl (n=9) and sufentanil (n=9) in a group of patients undergoing cardiovascular surgery. The opioid was administered after induction and took into consideration the EEG as well as cardiovascular signs indicative of anesthesia depth. Opioid comparisons included the following parameters: Times for anesthesia induction Return of consciousness Return of spontaneous ventilation Return event with cardiovascular status and Extubation. Using a test for significance in which p < 0.05, the following statistically significant shorter times for sufentanil compared to fentanyl or morphine reported as mean +/- standard error of the mean ( SEM) or reported as follows: Induction: (15 +/- 2.3 minutes, 5.9 +/- 0.7 minutes, 3.0 +/- 0.2 minutes for morphine, fentanyl, and sufentanil respectively. Return of consciousness: morphine 19.7 +/- 34.4 minutes, fentanyl 62.3 +/- 70.9 minutes, sufentanil 17 +/- 8.7 minutes. Return of acceptable and stable cardiac status: morphine 587.3 +/- 139.3 minutes, fentanyl 537.9 +/- 144.8 minutes, sufentanil 173.7 +/- 56.8 minutes. Extubation: morphine 1121.3 +/- 61.8 minutes, fentanyl 1005.7 +/- 77.7 minutes, sufentanil 533.3 +/- 67.8 minutes. The authors concluded that sufentanil administered in the dosage range of 19 g/kg will allow for more rapid induction as well as earlier anesthesia merchants and faster extubation of patients when compared with either morphine or fentanyl. Reference: Sanford, TJ, NT Smith, D Dec-Silver and WK Harrison, A comparison of morphine, fentanyl and sufentanil anesthesia for cardiac surgery: induction, emergence, and extubation Anesthesia & Analgesia, Vol 65, 259-266, 1986

¹Bailey, PL, Egan, TD, Stanley, TH, "Intravenous Opioid Anesthetics", in Anesthesia 5th edition, Miller, R.D., editor, Churchill Livingstone, Philadelphia, 2000, 273-377 (references secondarily sourced from this primary reference are noted below in the indented references)
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³Gottschalk, A and Smith DS, New Concepts in Acute Pain Therapy: Preemptive Analgesia, American Family Physician, May, 2001 http://www.aafp.org/afp/20010515/1979.html
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⁵Substantia Gelatinosa Image: Courtesy of The Digital Slice of Life, a cooperative project with the Slice of Life office, KUED Media Solutions, and the Knowledge Weavers Project.
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