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Clin Pod Med Exam III > 29: Pain Management - Mahoney > Flashcards

29: Pain Management - Mahoney Flashcards

1
Q

define pain

A

an unpleasant sensory AND emotional experience associated with actual or potential tissue damage, or described in terms of such damage

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2
Q

__________ of brain involved with sensory components of pain (location, intensity, quality), and the _________ system involved with emotional and cognitive aspects of pain

A
  • lateral area

- limbic forebrain

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3
Q

rules for PCA pump-patient controlled analgesia

A
  • alert patients
  • IV site
  • quick relief
  • morphine or hydromorphone are first line agents
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4
Q

why use PCA pump over the IV infustion?

A

IV infusion-avoids peaks and valleys, but may see more sedation; use PCA pump instead

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5
Q

the rectal dose is generally the same as …

A
  • equals oral dose
  • morphine and oxycodone available as suppositories
  • morphine works faster than oxycodone (30 min v. 90 min)
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6
Q

a phenol nerve block does what?

A
  • kills the nerve

- numb instead of pain

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7
Q

step one drugs

A
  • mild to moderate pain

- non-opiod (acetaminophen, NSAID, adjuvants)

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8
Q

do not exceed ______ mgs/day of acetaminophen or tylenol

A

3000-4000

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9
Q

what are the adjuvants?

A

all the “aunties”

- antidepressant, antihistamine, anticonvulsants, anti-anxiety agents, anti-inflammatories

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10
Q

drug of choice for bone pain

A

NSAIDs

  • Useful first line for all forms of cancer, arthritis, neuropathies
  • Use with caution with enteric ulcers, GI bleeds, thrombocytopenia, coagulopathies
  • Have a ceiling effect** (can’t exceed a certain amount)
  • Consider using cytoprotective agent (misoprostol or PPI)
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11
Q

antidepressants - which should you consider using with neuralgias

A

desipramine (Norpramine®), doxepin (Sinequan®), Nortriptyline (Pamelor®), duloxetine (Cymbalta®)

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12
Q

what anti-anxiety agents are useful in anxious patients?

A

lorazepam (Ativan®), clonazepam (Klonopin®), alprazolam (Xanax®)

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13
Q

which anticonvulsants should you consider using in neuropathic pain?

A

carbamazepine (Tegretol®), gabapentin (Neurontin®), pregabalin (Lyrica®)

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14
Q

which antihistamines are useful for agitation, may minimize pruritus associated with narcotics?

A

hydroxyzine (Vistaril®), promethazine (Phenergan®), diphenhydramine (Benadryl®)

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15
Q

_____ and _____ receptors when stimulated by glutamate cause pain.

_____ and ____ receptors (opioids) when stimulated cause analgesia.

A
  • NMDA and AMPA receptors when stimulated by glutamate cause pain
  • GABA and mu receptors (opioids) when stimulated cause analgesia
  • Most common use is to combine them in topical compounds
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16
Q

NMDA, Ca channel blockers

A
  • ketamine-requires close monitoring-not used often
  • Amantadine
  • pregabalin
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17
Q

AMPA, Na channel blockers

A
  • Gabapentin
  • Tegretol
  • lidocaine, melixitine
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18
Q

glutamate blockers

A
  • Gabapentin

- clonidine

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19
Q

GABA agonist

A
  • Baclofen
  • Benzodiazipines
  • topiramate
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20
Q

alpha-2 agonist

A
  • Clonidine

- prazosin

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21
Q

NE reuptake inhibitors

A
  • Tricyclic antidepressants
  • tramadol (Ultram)
  • duloxetine
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22
Q

substance P inhibitors

A

topical capsaicin

23
Q

alpha-1 antagonists

A
  • Prazosin

- phentolamine

24
Q

Non-NMDA calcium blockers

A

nifedipine

25
Q 
All of these are commonly used adjuvants for pain with narcotics, EXCEPT:
Ibuprofen
Phenergan®
Ativan®
Pregabalin
ketamine
A

ketamine - bad side effects

26
Q

step two

A
  • pts who fail step one or with moderate pain

- step two opiod ( codeine, oxycodone, hydrocodone) + nosteroidal or adjuvant

27
Q

Consider increasing the dose of the scheduled therapy if patient receives more than___ extra doses per day

A

two

28
Q

opiods cause constipation. how do you combat this?

A

senokot S bid

- senna (stimulates colon) + docusate (stool softner)

29
Q

why do opiods cause constipation?

A

Binding of opioids to peripheral opioid receptors in the GI tract results in:

  • absorption of electrolytes, such as chloride, with a subsequent reduction in small intestinal fluid.
  • abnormal GI motility.
30
Q

____ of the population are unable to convert codeine to morphine

A
  • 10%

- slow metabolizers

31
Q

what are the step two opioids?

A
    • Codeine or Tylenol (300 mgs) with codeine (#1, 2, 3, 4: 7.5, 15, 30, and 60mgs, respectively)
    • Hydrocodone or acetaminophen with hydrocodone (Vicodin®, Norco®, Lortab®, Lortab® elixir)
    • Hydrocodone-ibuprofen (Vicoprofen®)-200/7.5 mgs-administer after food with fluid
    • Oxycodone [Percocet®, Percodan®, generic, oxycodone controlled-release (Oxycontin®)]
    • Percocet® (oxycodone/acetaminophen) 325/2.5, 325/5, 325/7.5, 325/10 *** know dosages
32
Q

do narcotics have a ceiling effect?

A

No

give until it works or the side effects are too bad

33
Q

step three

A
  • pt who fail step tow or with severe pain

- step three opiod (morphine) + non-steroidal + adjuvants

34
Q

step three opiods

A
    • Morphine-available as MS Contin®; liquid available as Roxanol® (20mg/ml)
    • Hydromorphone (Dilaudid®)
    • Methadone (Dolophine®) - accumulation occurs over time; provide additional analgesic initially for breakthrough-respiratory depression common-requires 36 hours of observation after administration due to the discrepancy between analgesic effect and half-life (clearance from body may take up to 59 hours, while analgesic effects last only 4 to 8 hours)
35
Q

how do you use the fentanyl patch?

A

Fentanyl Patch®-change every three days; need to start on another opioid initially due to slow accumulation through skin for first 12 hours; start with 12ug/hr and increase up to 100 ug/hr if needed

36
Q

best for breakthrough pain

A

Transmucosal fentanyl®

  • works in 10 min
  • less constipation
  • ** only lipophilic narcotic
37
Q

________ are contraindicated for cancer pain and post-op pain due to fact that they are agonist/antagonist drugs

A

Talwin®, Nubain®, Stadol®, Buprenex®

38
Q

_____ does have addiction potential; use in caution in patients on SSRI’s (Prozac®)

A

ultram

39
Q

______ are an adjuvant when used to control headache, n/v associated with brain tumors; pain associated with spinal tumors, bony and neuropathic pain

A

corticosteroids

Dexamethasone-2-10mgs q6h po/IV

40
Q

what are the disadvantages of long duration opioids?

A
    • inconsistent release and absorption
    • potential systemic effects
    • continued occurrence of breakthrough pain in 50% to 90% of patients
41
Q

*** side effects of opioids

A
  • Sedation or euphoria [d/c narcotic]

- Constipation [laxatives]

42
Q

what is respiratory depression?

A

less than 10 bpm and pt somnolent

43
Q

how do you administer narcan and why? **

A
  • for respiratory depression
  • Narcan®, 0.4 to 2 mgs IV, IM or subQ every 2 minutes up to 10 mgs
  • O2 at 6 l/min via nasal cannula
44
Q

preferred choice to counteract N/V

A

Ondansetron (Zofran®)-4 mgs IV once-also available p.o

45
Q

drugs to combat N/V

A
    • -Promethazine (Phenergan®) or hydroxyzine (Vistaril®)- 25 mgs po, rectally, or IM q6h
    • Droperidol (Inapsine®)-0.625 mgs IV; 1.25 mgs IM
  • –Metocloparamide (Reglan®)-10 mg IV once; good for pre-op prevention in oral dose
    • Ondansetron (Zofran®)-4 mgs IV once-also available p.o. (preferred choice**)
46
Q

A patient calls you at home after surgery relating nausea and vomiting. Your best option is:

A

Phone pharmacy for Phenergan® suppository

47
Q

what can you use for sepsis-associated shivers?

A

Meperidine (Demerol®):5-25 mgs IV/IM every 10-15 minutes not to exceed 50 mgs

48
Q 
Relative Potencies *****
Morphine
Codeine and hydrocodone
Methadone
Oxycodone and hydrocodone 
Hydromorphone
Sublimaze (Fentanyl®)
A 
Morphine-1.0
Codeine and hydrocodone (?)-0.15
Methadone-1.5
Oxycodone and hydrocodone (?)-2.0
Hydromorphone-10.0
Sublimaze (Fentanyl®)-100.0
  • First, determine the total daily dosage of the current narcotic
  • Second, multiply by the potency factor if it less potent than the current drug or divide by the potency if it is more potent than the current drug
  • Patient on total daily dose of 20 mgs of morphine and you want to switch to oral oxycodone (20 mgs / 2 = 10 mgs of oxycodone daily )
  • Patient on total daily dose of 20 mgs of morphine and you want to switch to oral Tylenol #3 (20mgs x 7 = 140 mgs of Tylenol #3 daily)
49
Q

rule of “ 2s and 8s “ with PCA pump

A
  • 2 refers to the amount of analgesic in mgs or micrograms
  • 8 refers to time in minutes for the drug to reach maximum concentration in the blood
  • Loading dose-first dosage
  • Interval dose-subsequent dosages
  • Lockout-minimum time in minutes between consecutive doses
50
Q

PCA pump settings for morphine, dilaudid, fentanyl

A

morphine: 2 loading, 2 interaval, 8 lockout, 20 max dose
dilaudid: .2 loading, .2 interval, 8 lockout, 2 max dose
fentanyl: 20 ugs loading, 20 interval, 8 lockout, 200 max

51
Q

If the patient is not getting adequate control on the pain pump,________ minutes to find what works best for the patient.

A

double the dose every 8 min to find what works best for the pt

52
Q

Continuous infusion rates
Morphine:
Dilaudid:
Fentanyl:

A

Morphine: 2 mgs/hr
Dilaudid: 0.2 mgs/hr
Fentanyl: 25-50 ugs/hr

53
Q 
The strongest narcotic on a mg per mg basis is:
Morphine
Hydrocodone
Hydromorphone
Sublimaze
methadone
A

sublimaze

Clin Pod Med Exam III (13 decks)

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