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Stratification and doses of opioids for head and neck procedures

Stratification and doses of opioids for head and neck procedures
Stratification of opioid infusions for head and neck surgery
Degree of postoperative pain Opioid regimen
None to mild Remifentanil infusion ± fentanyl 1 mcg/kg total dose
Mild to moderate

Remifentanil infusion + fentanyl 1 to 3 mcg/kg total dose

or

Alfentanil infusion
Moderate to severe

Sufentanil infusion ± remifentanil infusion*

or

Fentanyl infusion ± remifentanil infusion*
Opioid doses for head and neck surgery[1-23]
Opioid IV load IV infusion
Fentanyl 3 to 7 mcg/kgΔ 0.7 to 2.5 mcg/kg/hour◊
Sufentanil 0.25 to 1.5 mcg/kgΔ
TCI: 0.4 to 0.5 ng/mL		 0.2 to 0.3 mcg/kg/hour
TCI: 0.2 to 0.65 ng/mL
Alfentanil§ 20 to 40 mcg/kg
TCI: 100 to 200 ng/mL		 0.25 to 1.5 mcg/kg/minute
TCI: 60 to 150 ng/mL
Remifentanil 0.5 to 2 mcg/kg
TCI: 4 ng/mL		 0.05 to 0.3 mcg/kg/minute
TCI: 1.5 to 9 ng/mL
TCI with opioids and propofol allows for easier and more rapid titration of drugs to patient responses and facilitates intraoperative hemodynamic control, as well as rapid recovery from anesthesia.

IV: intravenous; N2O: nitrous oxide; TCI: target-controlled infusion; TIVA: total IV anesthesia.

* May be additionally required during highly stimulating parts of the surgical procedure.

¶ Assumes: IV induction with propofol 1 to 2 mg/kg, maintenance of TIVA with propofol 80 to 180 mcg/kg/minute (TCI 3 to 5 mcg/mL), and no N2O administration.

Δ We titrate the loading dose of fentanyl or sufentanil using the clinical endpoints during induction, such as either a decrease of respiratory rate or onset of sedation.

◊ Fentanyl infusion should be used with caution and adjusted accordingly due to its long, context-sensitive half-life.

§ Alfentanil is no longer available in the United States or Canada, but remains available in some other countries.
References:
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  2. Jellish WS, Leonetti JP, Avramov A, et al. Remifentanil-based anesthesia versus a propofol technique for otologic surgical procedures. Otolaryngol Head Neck Surg 2000; 122:222.
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  11. Miller DR, Martineau RJ, O'Brien H, et al. Effects of alfentanil on the hemodynamic and catecholamine response to tracheal intubation. Anesth Analg 1993; 76:1040.
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  14. Jeon YT, Oh AY, Park SH, et al. Optimal remifentanil dose for lightwand intubation without muscle relaxants in healthy patients with thiopental coadministration: a prospective randomised study. Eur J Anaesthesiol 2012; 29:520.
  15. Demirkaya M, Kelsaka E, Sarihasan B, et al. The optimal dose of remifentanil for acceptable intubating conditions during propofol induction without neuromuscular blockade. J Clin Anesth 2012; 24:392.
  16. Stefanutto TB, Feiner J, Krombach J, et al. Hemoglobin desaturation after propofol/remifentanil-induced apnea: a study of the recovery of spontaneous ventilation in healthy volunteers. Anesth Analg 2012; 114:980.
  17. Gulhas N, Topal S, Erdogan Kayhan G, et al. Remifentanil without muscle relaxants for intubation in microlaryngoscopy: a double blind randomised clinical trial. Eur Rev Med Pharmacol Sci 2013; 17:1967.
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Courtesy of Dr. Vladimir Nekhendzy.

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