Journal of Clinical Anesthesia (2014) 26, S1S7

Special Article

Considerations for the use of short-acting opioids in

general anesthesia
Jeff E. Mandel MD, MS (Assistant Professor)
Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania,
Philadelphia, PA 19104, USA
Received 4 November 2013; accepted 25 November 2013

Keywords:
General anesthesia;
Propofol;
Total intravenous
anesthesia;
Short-acting opioids;
Remifentanil;
Alfentanil;
Sufentanil

Abstract Anesthesiologists play a critical role in facilitating a positive perioperative experience

and early recovery for patients. Depending on the kind of procedure or surgery, a wide
variety of agents and techniques are currently available to anesthesiologists to administer
safe and efficacious anesthesia. Notably, the fast-track or ambulatory surgery environment
requires the use of agents that enable rapid induction, maintenance, and emergence
combined with minimal adverse effects. Short-acting opioids demonstrate a safe and rapid
onset/offset of effect; that short effect is both predictable and precise. It also ensures easier
titration and reduced or rapidly reversed side effects. Due to their distinct pharmacokinetic
and pharmacodynamic properties, and, in one case, rapid extra-hepatic clearance of
remifentanil, these agents have several applications in general anesthesia.
2014 Elsevier Inc. All rights
reserved.

1. Introduction
General anesthesia is used to achieve a combination
of amnesia, analgesia, immobility, and sedation to
provide surgeons and proceduralists with optimal
working condi- tions. While general anesthesia may be
utilized with natural airways during procedures that are
minimally invasive, it more frequently is associated with
devices to maintain a patent airway. In the current fasttrack surgery environment, general anesthesia provides a
safe and comfortable experiFunding Sources: Mylan Specialty, LP, Canonsburg, PA, USA.

Correspondence: Jeff E. Mandel, MD, MS, Department of

Anesthe- siology and Critical Care, Hospital of the University of
Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104, USA. Phone: + 1
215-615-0553.
E-mail address: mandelj@uphs.upenn.edu.
0952-8180/$ see front matter 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jclinane.2013.11.003

ence that is coupled with reduced postoperative

recovery times and absence of overnight hospital stays [1].
However, general anesthesia is associated with side
effects such as nausea, vomiting, shivering, sore throat,
headache, malig- nant hyperthermia, and delayed return
to normal mental functioning [2]. Furthermore, general
anesthesia may affect cognitive function in the elderly
[3,4].
The
anesthesia provider also monitors
cardiovascular, pulmonary, neuro- logic, and renal
functions, and manages hemodynamic changes during
the perioperative period to minimize side effects while
decreasing postoperative pain and recovery times. The
anesthesia provider thus faces several challenges, one of
which is choosing an anesthesia regimen that will
provide
optimal
intraoperative
analgesia
and
postoperative amnesia while allowing for a rapid, yet safe
emergence and minimal postoperative side effects [2].

S2

2. Clinical considerations in
anesthesiology practice
Choice of anesthetic approach (local, regional, general,
or combination) affects patient outcomes. Factors that affect
the choice of anesthetic regimen include anesthesia
history, medical comorbidities, anatomical, lung function,
type and length of surgery, anticipated level of physical
manipulation during the surgical procedure, and,
subsequently, the level of anticipated pain. These and other
factors aid in planning the anesthetic approach. Although
certain factors such as smoking, obesity, diabetes,
and high blood pressure (BP) may increase the risk
of complications with general anesthesia, it remains the
preferred anesthetic approach for major surgeries [5].

3. Risk of intraoperative complications:

wakefulness and hemodynamic changes
The anesthesia provider distinguishes the risks from the
anesthetic agent versus those contributed by the patient,
allowing the technique to be individualized to a
patients particular needs. While anesthesia-specific
factors relate to drug effects, patient-specific factors (eg,
medical comor- bidities) must be analyzed, so that the
best efforts of the anesthesia provider are implemented
to avoid intra- operative complications.
One important consideration is the depth of anesthesia to
be achieved for the intervention. While moderate
sedation may be useful for short procedures, general
anesthesia with complete unawareness is a necessity for
surgical interven- tions. Inappropriate doses of the
principal anesthetic, depression, daily alcohol use, use
of certain drugs, and iatrogenic errors increase the risk of
unintended intraopera- tive awareness [6].
Hemodynamic changes defined as decreased or
in- creased heart rate and/or BP are also important
consider- ations. While hypertension and tachycardia
have been associated with inadequate anesthesia,
hypotension and bradycardia are side effects of anesthetic
agents. In addition, the type of procedure (cardiovascular
or noncardiovascu- lar), duration of procedure, and
patient
comorbidities strongly influence the range of
perioperative hemodynamic changes. The challenge is to
administer patient-individual- ized
anesthesia
and
achieve hemodynamic balance or prevent hypertension,
hypotension,
tachycardia,
and
bra- dycardia.
Furthermore, hemodynamic changes also occur in response
to actions (eg, application of vascular clamps) during
surgical procedures [7 9].
The American Society of Anesthesiologists
(ASA) physical status classification system [10] and the
American College of Cardiology and American Heart
Association
2007 Surgery
Guidelines
Perioperative
Care
for Noncardiac
[1113] on
are available
to
Cardiovascular Evaluation and
aid

J.E. Mandel
anesthesia providers in the stratification of patients based on
their overall risk of morbidity and mortality from their
surgery and the anesthetic regimen.

4. Practice recommendations for general

anesthesia
The practice recommendations by the ASA recently were
updated for the management of acute pain in
the perioperative setting. These guidelines recommend
mea- sures to be taken before, during, and after the
procedure to achieve minimal or no postoperative pain [14].
The updated ASA guidelines recommend institutional
policies and procedures to ensure that all healthcare
personnel
are familiar with safe and efficacious
techniques for adequate perioperative pain management.
These include ongoing education
and
training,
standardized and validated in- struments, and a
pivotal role for anesthesiologists in developing,
maintaining, and implementing policies [15,16]. For
preoperative evaluation of the patient, the updated
guidelines recommend including a directed pain history,
a directed physical examination, and a plan for pain control.
The guidelines recommend treatment of preexistent pain,
preoperative initiation of therapy for postoperative pain
management, and adjusting or continuing medications
before the procedure to avoid an abstinence syndrome.
Education and preparation of the patient for the procedure
to encourage reporting of pain, use of adequate
analgesic methods, and reduce side effects and anxieties
are also recommended [14,17 19]. More specifically,
therapeutic options such as epidural or intrathecal
opioids, systemic opioid as a patient-controlled
analgesic, and regional techniques must be considered
based on a risk-to-benefit assessment for individual
patients.
The
updates
also recommend patientindividualized
multimodal
techniques such
as
nonsteroidal
anti-inflammatory
drugs
(NSAIDs),
cyclooxygenase-2 (COX-2) inhibitors, acetaminophen, and
local anesthetics in combination with perioperative techniques for pain management. The updated guidelines also
note that pediatric, geriatric, critically ill, and
cognitively impaired patients, and those patients with
communication difficulties would require additional
interventions
for optimal
perioperative
pain
management. Historically, pediatric patients constitute an
undertreated subpopulation for perioperative pain
management and therefore proactive pain management
approaches that are developmentally appropriate are
recommended. The guidelines also recom- mend
multimodal approaches and highlight the need for
addressing the emotional component of pain management in
pediatric patients. In the case of geriatric
patients, perioperative strategies that include effective
pain
ment extensive,
tools, multimodal
techniques,
patientsassessmay require
proactive evaluation
and
assessment of comor- bidities, and dose titrations with
regard to polypharmacies and side effects are
recommended. Furthermore, geriatric

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