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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
``` All of these are commonly used adjuvants for pain with narcotics, EXCEPT: Ibuprofen Phenergan® Ativan® Pregabalin ketamine ```
ketamine - bad side effects
26
step two
- pts who fail step one or with moderate pain | - step two opiod ( codeine, oxycodone, hydrocodone) + nosteroidal or adjuvant
27
Consider increasing the dose of the scheduled therapy if patient receives more than___ extra doses per day
two
28
opiods cause constipation. how do you combat this?
senokot S bid | - senna (stimulates colon) + docusate (stool softner)
29
why do opiods cause constipation?
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
____ of the population are unable to convert codeine to morphine
- 10% | - slow metabolizers
31
what are the step two opioids?
- - 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
do narcotics have a ceiling effect?
No | give until it works or the side effects are too bad
33
step three
- pt who fail step tow or with severe pain | - step three opiod (morphine) + non-steroidal + adjuvants
34
step three opiods
- - 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
how do you use the fentanyl patch?
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
best for breakthrough pain
Transmucosal fentanyl® - works in 10 min - less constipation - ** only lipophilic narcotic
37
________ are contraindicated for cancer pain and post-op pain due to fact that they are agonist/antagonist drugs
Talwin®, Nubain®, Stadol®, Buprenex®
38
_____ does have addiction potential; use in caution in patients on SSRI’s (Prozac®)
ultram
39
______ are an adjuvant when used to control headache, n/v associated with brain tumors; pain associated with spinal tumors, bony and neuropathic pain
corticosteroids Dexamethasone-2-10mgs q6h po/IV
40
what are the disadvantages of long duration opioids?
- - inconsistent release and absorption - - potential systemic effects - - continued occurrence of breakthrough pain in 50% to 90% of patients
41
*** side effects of opioids
- Sedation or euphoria [d/c narcotic] | - Constipation [laxatives]
42
what is respiratory depression?
less than 10 bpm and pt somnolent
43
how do you administer narcan and why? ****
- 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
preferred choice to counteract N/V
Ondansetron (Zofran®)-4 mgs IV once-also available p.o
45
drugs to combat N/V
- - -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
A patient calls you at home after surgery relating nausea and vomiting. Your best option is:
Phone pharmacy for Phenergan® suppository
47
what can you use for sepsis-associated shivers?
Meperidine (Demerol®):5-25 mgs IV/IM every 10-15 minutes not to exceed 50 mgs
48
``` Relative Potencies ***** Morphine Codeine and hydrocodone Methadone Oxycodone and hydrocodone Hydromorphone Sublimaze (Fentanyl®) ```
``` 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
rule of " 2s and 8s " with PCA pump
- 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
PCA pump settings for morphine, dilaudid, fentanyl
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
If the patient is not getting adequate control on the pain pump,________ minutes to find what works best for the patient.
double the dose every 8 min to find what works best for the pt
52
Continuous infusion rates Morphine: Dilaudid: Fentanyl:
Morphine: 2 mgs/hr Dilaudid: 0.2 mgs/hr Fentanyl: 25-50 ugs/hr
53
``` The strongest narcotic on a mg per mg basis is: Morphine Hydrocodone Hydromorphone Sublimaze methadone ```
sublimaze

Clin Pod Med Exam III (13 decks)

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