Chapter 58. Opioids, Induction Agents, Neuromuscular Blockers

Brian J. Egan, MD, MPH

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AMA Citation
Egan BJ. Egan B.J. Egan, Brian J.Chapter 58. Opioids, Induction Agents, Neuromuscular Blockers. In: Atchabahian A, Gupta R. Atchabahian A, Gupta R Eds. Arthur Atchabahian, and Ruchir Gupta.eds. The Anesthesia Guide New York, NY: McGraw-Hill; 2013. http://accessanesthesiology.mhmedical.com/content.aspx?bookid=572&sectionid=42543643. Accessed June 19, 2018.

MLA Citation
Egan BJ. Egan B.J. Egan, Brian J.. "Chapter 58. Opioids, Induction Agents, Neuromuscular Blockers." The Anesthesia Guide Atchabahian A, Gupta R. Atchabahian A, Gupta R Eds. Arthur Atchabahian, and Ruchir Gupta. New York, NY: McGraw-Hill, 2013, http://accessanesthesiology.mhmedical.com/content.aspx?bookid=572&sectionid=42543643.

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Opioids

Medication	Pharmacology		Clinical pearls
Morphine	Class	Phenanthrene	IV/IM dosing equipotent IV dosing may produce less nausea/vomiting Active metabolite (morphine 6-glucuronide) accumulates with renal insufficiency/failure Intrathecal/epidural use: hydrophilic nature allows for single dose to have prolonged effect at the mu receptors within the substantia gelatinosa (12–24 h). Migration to brain stem can produce delayed respiratory depression
	Dose	1–3 mg
	Relative potency	1
	Onset/peak	5/20 min
	Metabolism	Hepatic
	Side effects	Causes common opioid side effects1 as well as histamine release
Hydromorphone (Dilaudid)	Class	Phenanthrene	Good alternative to morphine in renal insufficiency Purported to have less emetogenic effect compared with morphine
	Dose	0.1–0.4 mg
	Relative potency	7.5
	Onset/peak	5/20 min
	Metabolism	Hepatic
	Side effects	Common opioid side effects1
Meperidine (Demerol)	Class	Phenylpiperidine	Most effective opioid at decreasing postoperative shivering Use in renal insufficiency can lead to accumulation of the metabolite, normeperidine, which can cause seizures Atropine-like structure can increase HR; does not cause miosis
	Dose	12.5–100 mg
	Relative potency	0.1
	Onset/peak	5/20 min
	Metabolism	Hepatic
	Side effects	Interaction with MAOIs can cause fatal hypermetabolic reaction
Fentanyl (Sublimaze)	Class	Phenylpiperidine	Use as analgesic component of TIVA at 0.2–1.5 μg/kg/h Context-sensitive half-time (CSHT) leads to prolonged elimination with infusions greater than 2 h Terminate infusion 30 min prior to expected emergence to allow drug accumulated in other compartments to be eliminated
	Dose	25–50 μg
	Relative potency	100
	Onset/peak	1/5 min
	Metabolism	Hepatic
	Side effects	Common opioid side effects1 and chest wall rigidity
Sufentanil (Sufenta)	Class	Phenylpiperidine	As component of TIVA has more favorable CSHT but will accumulate with longer infusions Very rapid onset
	Dose	5–10 μg
	Relative potency	1,000
	Onset/peak	30 s/1 min
	Metabolism	Hepatic
	Side effects	Common opioid side effects1
Alfentanil (Alfenta)	Class	Phenylpiperidine	Good alternative to remifentanil as bolus agent for brief periods of more intense stimulation Good choice of analgesic component of TIVA (0.5–3 μg/ (kg min)) when duration anticipated to be longer than 8 h (although remifentanil still superior in terms of recovery)
	Dose	100–300 μg
	Relative potency	15
	Onset/peak	30 s/1 min
	Metabolism	Hepatic
	Side effects	Common opioid side effects1 Chest wall rigidity at high doses or with rapid administration
Remifentanil (Ultiva)	Class	Phenylpiperidine	With a flat CSHT with infusion of any duration, excellent TIVA component Rapid onset and offset makes it good for blunting sympathetic effects of brief periods of increased stimulation Very-low-dose infusions can be used for sedation; however, works synergistically with propofol to cause respiratory depression and apnea
	Dose	5–50 μg IV
	Relative potency	100
	Onset/peak	30 s/1 min
	Metabolism	Tissue esterases
	Side effects	Common opioid side effects.1 Acute opioid desensitization, hyperalgesia

1Common opioid side effects include nausea/vomiting, respiratory depression, urinary retention, pruritus, constipation, sedation, and miosis. Doses given are typical one-time bolus doses, not total doses for a given procedure.