Peran Fentanyl pada balance anestesia -> telah banyak diteliti hasilnya adanya potensiasi fentanyl dengan obat anestesia baik inhalasi maupun intravena. Berikut ini kami mencoba menelaah beberapa penelitian dari luar maupun penelitian yang kami lakukan sendiri.

1. The Role of Fentanyl in
Balance Anethesia
Muh. Ramli Ahmad
Department of Anesthesiolgy, IC and Pain Management
Faculty of Medicine, Hasanuddin University
Makassar, Indonesia

2. INTRODUCTION
General Anesthesia
Goals of surgical anesthesis
1. Loss of pain sensation
2. Loss of consciousness
3. SKM relaxation
4. Autonomic stabilization

3. General
Anesthesia
Loss of
Consciousness
Analgesia
Reversible
Relaxation
INTRODUCTION
Opioid in medicine, Enno Freye, Joseph Victor levy, University of Pacific, Webster Street, Sanfransisco,California, USA, Spinger
2008;191-240
Autonomic
stabilization
TIVA : total intravenous anesthesia
VIMA : Volatile induction Maintanance Anestesia

4. Goals of General Anesthesia
• Hypnosis (unconsciousness)
• Amnesia
• Analgesia
• Immobility/decreased muscle tone
– (relaxation of skeletal muscle)
• Inhibition of nociceptive reflexes  MAC
• Reduction of certain autonomic reflexes
– (gag reflex, tachycardia, vasoconstriction)  MAC-BAR
( blockade adrenergic response)

5. Traditional monoanesthesia
High dosage of Inhalation
Anesthetic
Loss of Consciousness -
Analgesia
Subcortical / Limbic
System
Brain stem depression,
Turmoil of Respiration and
Hemodynamic ambiance
Opioid in medicine, Enno Freye, Joseph Victor levy, University of Pacific, Webster Street, Sanfransisco,California,
USA, Spinger 2008;191-240

6. Modern balanced anesthesia
Inhalation Anesthetic Loss of consciousness +
Analgesia
Fentanyl
Opioid in medicine, Enno Freye, Joseph Victor levy, University of Pacific, Webster Street,
Sanfransisco,California, USA, Spinger 2008;191-240

7. Opioid in Balanced Anesthesia
• Furthermore in one study of 150 elective ASA I-III, surgical patients aged
65-92 years old showed that:
– Fentanyl reduced the rises in systolic, diastolic and mean arterial
pressures, heart rate, and rate pressure product (P < 0.05)
– Fentanyl decreased the incidence of marked fluctuations in
hemodynamic variables, often seen in geriatric patients (P < 0.05).
Splinter WM, Cervenko F. Haemodynamic responses to laryngoscopy and tracheal intubation in geriatric patients: effects of
fentanyl, lidocaine and thiopentone. CAN J ANAESTH 1989. 3 6; 4:3 7 0 – 6

8. Traditional monoanesthesia vs. modern
balanced anesthesia
Traditional monoanesthesia modern balanced anesthesia

9. FARMAKOEKONOMI
• Biaya opersional rumah sangat meningkat 
terutama kamar operasi
• Data  biaya dikeluarkan RS  6% obat
anestesi dari seluruh pembelian obat di RS
Dari 6%  20% adalah obat inhalasi.
• Mulai dikembangkan Farmakoekonomi

10. FARMAKOEKONOMI
Farmakoekonomi adalah subdisiplin ilmu ekonomi
kesehatan yang membandingkan biaya dan
efektivitas suatu obat terhadap obat lain serta
melakukan analisis keduanya
Analisa ini untuk memberikan pelayanan kesehatan
berdasarkan nilai yaitu mendapatkan hasil yang
terbaik dengan biaya yang murah
Telah berkembang dinegara maju seperti Amerika
serikat, Jerman dan Australia

11. The Role of Fentanyl in Balance Anesthesia
The Potentiation of Anesthetic Agents with Fentanyl
• Rapid induction
• Analgesia
• Inhibition of nociceptive reflexes
• Farmakoekonomi / cost effective
• Decrease the MAC
• Reduction of certain autonomic reflexes
– (gag reflex, tachycardia, vasoconstriction)

12. Fentanyl
• Penggunaan paling sering dari fentanyl adalah sebagai agen
analgesik selama pemberian balanced anesthesia. Dosis
fentanyl sebesar 0.5 – 2.5 mcg/kg dilakukan secara intermiten
disesuaikan dengan intensitas pembedahan dan dapat diulang
kurang lebih setiap 30 menit.
• Dosis alternatif, pemberian loading dose 5-10 mcg/kg dan
infus kontinu fentanyl pada kecepatan antara 2-10
mcg/kg/jam dapat direkomendasikan.

13. Fentanyl
• Onset kerja fentanyl singkat, namun peak effect
tercapai dalam waktu 5 menit.
• Pada praktek klinis secara umum, dosis fentanyl
yang digunakan sebelum dimulai induksi adalah
1,5 sampai 5 mcg/kg.
• Titrasi fentanyl dilakukan sekitar 3 menit sebelum
dilakukan laringoskopi karena efek puncaknya
yang mengalami perlambatan sekitar 3-5 menit
untuk mendapatkan efek yang maksimal.

14. Fentanyl Pharmacokinetics
• Intramuscular
Onset 7-15 minutes
Peak 15 minutes
Duration 1-2 hours
• Intravenous
Onset minutes
Peak minutes
Duration 30-60 minutes

15. Adverse Reactions:
 MS: Muscle rigidity, particularly involving
muscles of respiration.
 CV: Bradydysrhythmias (common) or
tachydysrhythmias, hypotension,
orthostatic hypotension
 Resp: Respiratory depression (common) or arrest.
 CNS: Pupillary constriction. Sedation
 GI: Nausea and Vomiting
 Derm: Histamine release may cause local or
general urticaria

16. Modern balanced anesthesia
Opioid in medicine, Enno Freye, Joseph Victor levy, University of Pacific, Webster Street,
Sanfransisco,California, USA, Spinger 2008

17. The Potentiation of Anesthetic Agents with
Fentanyl
Inhalation Agent Inhalation Agent + Opioid

18. MAC Reduction of isoflurene by increasing
concentrations of fentanyl
A.I. McEwan .Anestesiology 78T. 864-869 tahun 1993

19. MAC Reduction of isoflurene by
increasing concentration of fentanyl

24. Fentanyl menurunkan MAC agen
anestesi inhalasi
(From Katoh T et al: Sevoflurane Requirements for tracheal intubation with and without fentanyl. British Journal of Anesthesia 1999.)

26. Reduction in MAC, MAC-BAR and MAC Awake of
sevoflure by increasing concentration of fentanyl
Takasumi Katoh dkk 199

27. Fentanyl menurunkan MAC agen anestesi inhalasi seperti sevoflurane
(From Katoh T, Kobayashi S, Suzuki A, et al: The effect of fentanyl on sevoflurane requirements for somatic and sympathetic responses to surgical incision.
Anesthesiology 90:398-405, 1999.)

30. The Potentiation of Anesthetic Agents with Fentanyl
Katoh and Ikeda,
1999
The Potentiation of Sevoflurane and Fentanyl with Fentanyl Dosage
Regiment of 0, 1, 2 and 4 μg/kg BW
Result: Fentanyl 4 μg/kgBW was the most effective in decreasing
autonomic stimulation along with decreasing Sevoflurane
consumption during operation
Xuan Wang
2008
The Potentiation of Enflurane and Fentanyl on Pediatric
Patient
Result: Fentanyl group showed decreasing Enflurane
MAC level

32. MAC-BAR : MAC Blockade Adrenal Response

34. MAC : MAC tracheal intubation

38. Fentanyl effect on MAP and HR
Fentanyl dosis 4 mcg/kg menurunkan denyut jantung dan MAP lebih efektif dari
pada 1 atau 2 mcg/kg
(From Katoh T et al: Sevoflurane Requirements for tracheal intubation with and without fentanyl. British Journal of Anesthesia 1999.)

39. Fentanyl administration before intubation
• Most effective : 5 minutes before intubation
(dosis pre-intubasi 2 mcg/kg)
Ko SH et al. Small Dose Fentanyl Optimal Time of Injection for Blunting the Circulatory
Response to tracheal intubation. Anesth Analg 1998

40. Fentanyl administration before intubation
(dosis pre-intubasi 2 mcg/kg)
Channaiah et al. Low dose fentanyl : hemodynamic response to endotracheal intubation in
normotensive patients. Arch Med Sci Journal 2008

41. Fentanyl administration before intubation
Premedication fentanyl added to the propofol regimen was shown able
to reduce Systolic Blood Pressure (SBP) response due to airway
manipulation (dosis pre-induksi 2 mcg/kg)
*P <0.05
Adachi A, et al. Fentanyl Attenuates the
Hemodynamic Response to Endotracheal Intubation
More Than the Response to Laryngoscopy. Anesth
Analg 2002;95:233–7

42. Fentanyl administration before intubation
• Premedication fentanyl also affected Diastolic Blood Pressure (DBP) response due
to airway manipulation (dosis pre-induksi 2 mcg/kg)
*P <0.05
Adachi A, et al. Fentanyl Attenuates the
Hemodynamic Response to Endotracheal Intubation
More Than the Response to Laryngoscopy. Anesth
Analg 2002;95:233–7

43. THE COMPARISION OF 4 μG/KgBW and 2 μG/KgBW FENTANYL to
HEMODYNAMIC STABILITY along with ISOFLURANE CONSUMPTION in
LAPAROTOMY GYNECOLOGIC SURGERY
ABDUL MUTTALI . MUH.RAMLI AHMAD

44. Patient
2μg/kg BWFentanyl
Group (N=14)
Laparotomy Gynecology
4μg/kg BW Fentanyl
Group (N=14)
Procedure
Fit The Inclusion
criteria
Premedication midazolam 0,05
mg/kgBW
Induction propofol 2-2,5
mg/kg BW
Atracurium 0,5
mg/kgBW Maintenace
Intubation + Surgery
Response
Isoflurane
Consumption
Monitoring
HR,TD,BIS,TOF ETCO2,
(+) Isoflurane 0,5 %
Metode
Hemodynamic
Fluctuation (+)
Rescue Fentanyl
(--) Isoflurane 0,5%

45. Grafik perbandingan tekanan darah sistolik antara kedua kelompok
160
140
120
100
80
60
40
20
0
Sblm
ind
Sdh
ind
Sdh
int
5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110 115
Kontrol
Perlakuan
0.924
P =
0.387
0.101
0.002
0.026
0.004
0.008
0.023
0.026
0.035
0.071
0.002
0.011
0.040
0.008
0.023
0.048
0.208
0.002
0.000
0.002
0.002
0.000
0.001
0.093
0.028
tekanan darah sistolik (mmHg)
TEKANAN DARAH SISTOLIK

46. TEKANAN DARAH DIASTOLIK

47. LAJU JANTUNG

48. Comparison of Rescue Dose on Both Group
Control Group Experiment Group P
RESCUE DOSE 130.71 ± 45.987 24.64 ± 29.64 0,0000
All data was shown as mean value and tested with Mann Withney U test as significant was
pronounced when p value less than 0.05
Comparison of Rescue Dose on Both Group

49. Comparison of Isoflurane Consumption
GROUP
Isoflurane Consumption Control Experiment p
47.0871 ± 2.430
KEBUTUHAN ISOFLURAN
KELOMPOK KONTROL
K.PERLAKUAN
Figure 4. Comparison of Isoflurane consumption on both group
35.8736± .996
0,0000
All data was shown as mean value and tested with Mann Withney U test as significant was pronounced when p value less than 0.05

50. RESULT
Fentanyl 4 μg/kgBB Vs 2μg/kgBB
Better Hemodynamic Stability
Less Rescue Dose
Less Isoflurane Consumption

51. Conclusions
• Fentanyl produces a reduction in the minimum alveolar
concentarion ( MAC) of isoflurene, sevoluren and
desflurance
• Minimum alveolar concentarion (MAC) and Minimum
alveolar concentarion blockade adrenergic response
(MEC BAR)  MAP and heart rate decreased similarly
with creasing concentrations of fentanyl in plasma.
• Somatic and symphatetic responses to surgycal incision
are clinical end points for assessing depth of anesthesia
• The intraction of fentanyl on the Cp50 of Propofol and
Thiopental.

52. Thank you!
FOR YOUR ATTENTION

53. • Isoflurane consumption was total of isoflurane
for the whole operation (ml) and calculated
with the following equation :
Vol : C x Flow O2 x 1/ Vapour pressure x T
C:Mean concentration of the anesthetic volatile agent (vol%, T; Duration
of the operation, Flow O2: O2 flow (l/mnt), (Vapour pressure isoflurane :
240 )