31- Medication

Question 1

Why do ortopedists treat pain more frequently than other specialists?

Answer 1

Because for the majority of musculoskeletal conditions, pain is the chief complaint

Question 2

When are opioids are used to treat pain?

Answer 2

Acute, severe pain-such as postoperative pain

Question 3

What is the most commonly used opioid anagesic?

Answer 3

Morphine (codeine, hydrocodone, oxycodone, meperidine, and fentanyl are used too)

Question 4

What is the method of delivery of opioids such as morphine?

Answer 4

orally, rectally, intramuscularly or intravenously

Question 5

What has been the traditional approach to postoperative pain control with opioids?

Answer 5

On-demand intramuscular opioid delivery (in which a pt must report pain and request medication)

Question 6

What is patient-controlled analgesia (PCA)?

Answer 6

It’s a method to deliver any of several intravenous or epidural opioids via a pump that is controlled by the patient; the pump can be regulated to minimize the likelihood of overdose or respiratory depression

Question 7

Why do patients like PCA’s?

Answer 7

deliver any of several intravenous or epidural opioids via a pump that is controlled by the patient; the pump can be regulated to minimize the likelihood of overdose or respiratory depression

Question 8

When can pt’s be swtiched to oral analgesics from parenteral meds?

Answer 8

If a patient is expected to have significant pain at a continuous level for several days, a longer-acting oral opioid can be administered to permit once- or twice-daily dosing; this reduces the chances of the analgesics reaching a subtherapeautic concentration.

Question 9

Why are NSAIDS and opioids used together in synergy?

Answer 9

It allows the use of a lower opioid use

Question 10

How is acetaminophen different than NSAIDs?

Answer 10

Acetaminophen has analgesic and antipyretic properties, it has no proven anti-inflammatory effects and does not reduce platelet aggregation as does NSAIDs.

Question 11

What is Tramadol used for?

Answer 11

Tramadol effectively controls pain resulting from postoperative surgical trauma and malignant/non-malignant disease states

Question 12

All NSAIDs inhibit prostaglandin formation by blocking what enzyme?

Answer 12

Cyclooxygenase (COX)

Question 13

What does COX-1 do?

Answer 13

present in most bodily tissues (including platelets and GI mucosal tissues) and serves as a “housekeeping” enzyme to form protective prostaglandins.

Question 14

What does COX-2 do?

Answer 14

not present in most tissues unless induced in response to inflammation; it is responsible for the formation of prostaglandins that contribute to pain and inflammation.

Question 15

How can NSAIDS cause HTN?

Answer 15

NSAIDs also can adversely affect blood pressure, sometimes through fluid retention, or can be a primary cause of hypertension because of adverse effects on the kidneys.

Question 16

Why are antidepressants sometimes used to treat atypical musculoskeletal pain?

Answer 16

they seem to have analgesic effects in addition to their function as antidepressants

Question 17

Why are anticonvulsants sometimes used to treat atypical musculoskeletal pain?

Answer 17

been found to be helpful in treating pain that is neurogenic in nature, presumably through a mechanism that is similar to their anticonvulsant properties

Question 18

When are anxiolytics used?

Answer 18

used alongside analgesics to alleviate anxiety often associated with painful conditions or surgery

Question 19

What is Viscosupplementation?

Answer 19

the intra-articular injection of hyaluronic acid products to treat pain associated with osteoarthritis of the knee for only a short time.

Question 20

How can diarthrodial joint injections be diagnostic?

Answer 20

pain relief from an intra-articular injection- even if only temporary- strongly suggests that the painful pathology is intra-articular rather than peri- or extra-articular.

Question 21

How can diarthrodial joint injections be therapeutic?

Answer 21

The therapeutic effect of these injections is variable, depending on the joint, the etiology of disease, and associated rehabilitative interventions.

Question 22

What are periarticular injections used for?

Answer 22

treatment of bursitis

Question 23

Which drugs are used in periarticular injections?

Answer 23

Most corticosteroid injections are given in conjugation with short- and long-acting local anesthetics; to provide immediate relief and minimize the burning sensation

Question 24

What drugs are used for intraarticular injections?

Answer 24

Corticosteriods (typically given w/ an anesthetic) & Hyalectin

Question 25

Why are tendon sheath injections not commonly done in the achillies tendon?

Answer 25

Achilles tendon and anterior tibial tendon ruptures have been reported after corticosteroid injections to those structures

Question 26

Why are corticosteroids given in emergent orthopedic situations?

Answer 26

Corticosteroids are also used in the emergency setting to decrease the swelling associated with spinal cord trauma. If given within 8 hours of spinal cord injury, high-dose intravenous steroids have been shown to help lessen the severity of the injury. They are even more effective if given within 3 hours of injury.

Question 27

How do Symptom-Modifying Antirheumatic Drugs (SMARDs) treat RA?

Answer 27

consists primarily of NSAIDs and oral steroids; this class is used to decrease pain and inflammation quickly and to suppress chronic inflammation however they do not affect disease progression or avert the longterm destructive sequelae of RA

Question 28

How do Disease-Modifying Antirheumatic Drugs (DMARDs) treat RA?

Answer 28

comprise a class of drugs that includes a number of agents with dissimilar mechanisms of action and includes many of the drugs formerly classified as “slow-acting,” “second-line,” or “remittive agents” for the treatment of RA; these drugs work to blunt the immune response and slow or halt the destructive effects of inflammatory arthritis. Three examples are Leflunomide (a dihydroorotate dehydrogenase inhibitor), etanercept (a tumor-necrosis factor inhibitor), and methotrexate (mainstay in RA therapy).

Question 29

What are the adverse effects to corticosteroid use?

Answer 29

interference with insulin fxn and lipogenesis, promotion of osteoporosis, edema, HTN, hypokalemia, poor skin wound healing, susceptibility to infections, cataracts, glaucoma, ulcers, and pancreatitits

Question 30

What are the 3 common areas of osteoporotic hip Fx’s?

Answer 30

Spine, hip, and wrist

Question 31

What are the the non-pharmaceutical preventions to osteoporosis?

Answer 31

Weight-bearing exercise, smoking cessation, good nutrition (especially sufficient nutritional intake of calcium and vitamin D), and avoidance of excess alcohol intake

Question 32

What is the primary primary reason for bone loss in women who are within 5 years of menopause?

Answer 32

Estrogen is primarily responsible for bone loss.

Question 33

How does calcitonin inhibits bone resorption?

Answer 33

t inhibits bone resorption through a direct inhibition of osteoclasts, which have a high affinity for calcitonin.

Question 34

How do bisphosphonates inhibit bone resorption?

Answer 34

by interfering with osteoblast ruffled border membranes.

Question 35

What is the risk of DVT in orthopedic surgery?

Answer 35

Patients undergoing major orthopaedic surgery on the lower extremeties have a higher risk for the development of deep venous thrombosis (DVT) or pulmonary embolism (PE) than any other group of surgical patients, and those undergoing joint replacement or surgery for pelvic trauma are at greatest risk

Question 36

What are the non-pharmacological approaches to prophylaxis of thrombin embolism?

Answer 36

Mobilization, compressive stockings, compressive devices, alterations in anesthesia technique and preop collection of autologous blood

Question 37

What is the only oral anticoagulant approved by the FDA for thromboprophylaxis?

Answer 37

Warfarin

Question 38

How does Warfarin work?

Answer 38

It works by reducing the synthesis of vitamin K-dependent clotting factors II, VII, IX, and X in the liver; it does not have immediate effect on clotting because the body’s supply of these factors are not depleted for at least 8 hrs

Question 39

How do low-moleculer weight heparin products work?

Answer 39

by binding to antithrombin-III and catalyzing its inactivation of factor Xa

Question 40

which thromboprophylactic agent is particularly useful in hypotensive epidural anesthesia?

Answer 40

Aspirin

Question 41

What are the indications for prophylactic antibiotics in orthopedic surgery?

Answer 41

Antibiotics are used in most surgeries especially whenever hardware is implanted because infected artificial joint prostheses result in such severe morbidity that even small decreases in the rate of infection provide a very meaningful advantage

Question 42

What is the critical window for prophylactic antibiotics in orthopedic surgery?

Answer 42

2-hour period before surgery is the critical window

Question 43

What is the antibiotic of choice for clean orthopedic cases?

Answer 43

For “clean” cases (those w/o prior infection or skin breakdown), most surgeons choose first-generation cephalosporins for prophylaxis

Question 44

How do 1st generation cephalosporins (like cegazolin sodium) work?

Answer 44

Its action blocks the transpeptidation of peptidoglycan and thereby inhibits bacterial cell-wall synthesis, it also activates autolytic cell-wall enzymes, resulting in bacterial death

Question 45

How long are long post-op prophylactic antibiotics used?

Answer 45

For joint replacement procedures in which bone or joint is exposed, antibiotics should be started preoperatively and continued for 24-48 hours.