3.1 Multimodal Pain Mgmt Flashcards
What is the MOA of NSAIDs? Benefits? With whom should you use with caution? What is important re: efficacy?
MOA: Inhibit COX1 and/or COX2, decreasing prostaglandin production and inflammation.
Benefits: Non-sedating, no abuse, inexpensive.
Use with caution: CV risk factors, GI bleed, 3rd trimester preg, renal disease, medication interactions.
Efficacy: Naproxen 500-550mg effective for mod-severe post-op pain. No difference btwn ibuprofen and apap, norco, and percocet for acute extremity pain in ED.
Name the ester and amide local/regional anesthesia. What is the MOA? What are the benefits?
Esters: cocaine, procaine, chloroprocain, tetracaine.
Amides: lidocaine, mepivacaine, bupivacaine, etidocaine, prilocaine.
MOA: inhibit depolarization of nerve cell membrane.
Benefits: low risk of local or systemic complications; rapid onset; lasts up to 6h anesthesia; bypasses opioid mechanism.
You consider IV lidocaine for pain management. What is normal dose? What worries you for toxicity? What are the benefits? What is the evidence base?
Dose: 1-1.5mg/kg IV, max 4mg/kg or 300mg.
Lidocaine tox: paresthesia, restlessness, muscle fasciculation, confusion, seizure, hypotension, bnradycardia, dysrhythmia, cardiac arrest.
Evidence: Similar efficacy to morphine for ureterolithiasis and acute extremity pain; leads to reduced opiate use post-op.
Use with caution: structural heart dz or hx of dysrhythmia, and in pregnant women. Benefits: Low side effect profile.
Describe the MOA of ketamine. What are the anesthetic and subdissociative doses? Describe benefits and limitations.
MOA: NMDA antagonist; blocks glutamate (which is co-ligand for NMDA).
Dosing: Anesthetic 1-4.5mg/kg; Subdissociative 0.1-0.5mg/kg IV.
Benefits: comparable to morphine for acute pain control with mild SEs in ED medicine. Post-op pain reduction and opioid consumption reduction with low-dose ketamine adjunct. Safe in hypotension and tachycardia.
Limitations: Higher rate of mild AEs (hallucinations, emergence phenomenon, dysphoria). May cause transient HTN and increased ICP.
What are the two major gabapentinoids? What is MOA? What are benefits and evidence base? What is limitation?
Drugs: Gabapentin and pregabalin.
MOA: Similar to GABA, decrease neurotransmission, exact MOA unknown but causes hyperpolarization to prevent nerve transmission.
Benefits: tx of neuropathic pain; adjunct therapy for post-op pain; decrease in morphine consumption and N/V post-op using pregabalin.
Limitation: Potential abuse/misuse, esp with hx of opioid abuse.
What schedule drug is tramadol? What is MOA? What are risks? What are benefits?
Schedule: IV, synthetic codeine analog.
MOA: Binds to mu receptors and prevents reuptake of NE and serotonin.
Risks: Serotonin syndrome, seizure, overdose, dependence, abuse, similar to other opioids.
Benefits: Causes less respiratory depression c/w other opioids.
What are MOA for opioids? What is indication? What is recommendation re: mild-moderate or chronic non-cancer pain? Which drug is best for unstable vital signs? What are limitations?
MOA: Acts on endogenous opioid receptors.
Indication: fast-acting relief of acute severe pain.
Recommendation: NOT for mild-mod/chronic non-cancer pain.
Unstable: Fentanyl, less vasoactive.
Limitations: High abuse, addiction potential; cardiopulmonary and CNS depression; low efficacy in chronic paion, HA, back pain, neuropathic pain
Your patient is getting a painful bedside procedure and requires procedural sedation. Describe minimal, moderate, deep sedation, and general anesthesia in this context.
Minimal: Anxiolysis, can respond normally verbally. Cardiopulmonary functions preserved. Coordination and cognitive function may be impaired.
Moderate: Somewhat decreased LOC, can respond verbally but may need light stimulation, airway patent, ventilation adequate. Cardiovascular function preserved.
Deep: cannot be aroused by voice, can respond to painful or vigorous stimuli; may require airway/ventilatory support; cardiovascular function preserved, some drugs may induce bradycardia or hotn.
General anesthesia: patient not arousable, requires airway/ventilatory support, CV function may be impaired.
Describe special considerations in pain mgmt for the following populations: pregnancy, elderly, active mental illness.
Pregnancy: caution w IV lidocaine, NSAIDs in 3rd tri, ketamine, gabapentin.
Elderly: Decreased renal/liver fct, higher fall risk, delirium, polypharm.
Active mental illness: Avoid tramadol (SSRIs, SNRIs, seratonin syndrome risk), higher risk for abuse, addiction, OD.
