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Acute Pain Flashcards

1
Q

What is ketorolac?

A

Very potent NSAID

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2
Q

What is the onset of analgesia for ketorolac?

A

30 min

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3
Q

What is the peak effect of ketorolac?

A

2-3 hours

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4
Q

What is the duration of ketorolac?

A

4-6 hours

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5
Q

When is ketorolac contraindicated?

A

Labor and delivery

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6
Q

What do all NSAIDs increased the risk of in post-op CABG surgery?

A

MI and Stroke

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7
Q

What are the 3 IV opioids?

A

Morphine
Hydromorphone
Fetanyl

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8
Q

Which IV opioid accumulates in renal impairment?

A

Morphine

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9
Q

How does morphine cause hypotension?

A

Histamine release

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10
Q

What is a good IV alternative for morphine-intolerant pts?

A

Hydromorphone

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11
Q

What do all IV opioids cause?

A

Hypotension

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12
Q

What is similar to fentanyl in potency and PK parameters?

A

Remifentanil

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13
Q

What kind of metabolism does remifentanil show?

A

Organ-independent

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14
Q

When is meperidine used?

A

Labor and delivery

Reduce rigors associated w/amphotericin toxicity

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15
Q

What may be found PRN on a chart if the patient is receiving IV opioids?

A

Naloxone

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16
Q

Why does naloxone require repeated doses?

A

Short 1/2 life elimination compared to opioids

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17
Q

What is the onset of IV naloxone?

A

2 min

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18
Q

Who should not receive PCA?

A 
Dementia
Delirium
Cognitive deficits
H/o substance abuse
Anticipated short duration of opioid use
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19
Q

Who has an indication for PCA?

A 
Post-op pain
Severe pain
Cancer pain
Sickle cell crisis
Palliative care
Burn pts
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20
Q

What are the goals of PCA therapy?

A

Pain score 4 or less
Avg 2-3 PCA doses/hr
Maintain O2 sat and RR
Wean off PCA, decrease basal rate

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21
Q

What is the first step in adjusting PCA in opioid-naive patients?

A

Increase dose first

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22
Q

What do we do if increasing the dose of PCA is not enough for the pain?

A

Consider adding basal rate (if not prescribed already)

Start at low end of dosing range or 1/3 of average hourly usage for at least the past 12 hours

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23
Q

How do we adjust PCA doses in opioid tolerant patients?

A

Increase basal rate up to 2/3 of average hourly usage

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24
Q

How do we start PCA in a opioid tolerant patient?

A

Will likely need basal rate and higher PCA dose

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25
What are ways to administer spinal opioids?
Epidural | Intrathecal
26
When is neuraxial analgesia indicated?
Post-op pain Labor and delivery Chronic pain
27
Where is an epidural administered?
Outside the dura mater Space b/n the dura mater and ligamentum flavum Contains fat, lymphatics, arterioles, and veins w/nerve roots
28
How does the drug that is administered via an epidural make it into the CSF?
Drug diffuses through the dura into the CSF
29
Where is an intrathecal opioid administered?
In the space under the arachnoid membrane Intrathecal space = subarachnoid space -B/n the arachnoid mater and pia mater -Contains CSF
30
How does the drug that is administered via an intrathecal injection make it into the CSF?
Drug is delivered directly into the CSF and superficial spinal cord
31
What are the approximate equivalencies of morphine from an IV to epidural to intrathecal dose?
10mg IV = 1mg epidural = 0.1mg intrathecal
32
Which opioids used in neuraxial analgesia are highly lipid soluble?
Fentanyl | Sufentanil
33
Which opioids used in neuraxial analgesia have lower lipid solubility?
Morphine | Hydromorphone
34
Which neuraxial analgesics have a rapid onset of analgesia?
Fentanyl | Sufentanil
35
Which neuraxial analgesics have a delayed/slower onset of analgesia?
Morphine | Hydromorphone
36
Which neuraxial analgesics are more rapidly cleared from the CNS?
Fentanyl | Sufentanil
37
Which neuraxial analgesics have a prolonged half life in the CNS?
Morphine | Hydromorphone
38
What is a serious AE of neuraxial analgesics?
Hematoma formation
39
What increases the risk of a hematoma formation?
Anticoagulants | Antiplatelets
40
When is the risk of a hematoma forming greatest?
During placement/removal of catheter
41
When is neuraxial analgesia contraindicated?
Uncorrected coagulopathy Infection of the lower back Uncorrected hypovolemia Increased intracranial pressure
42
What type of solution must intrathecal and epidural agents be?
PF
43
When is the risk of long term treatment increased in opioid-naive, non-cancer pts?
With each additional day of medication use after 3 days After a second prescription/refill 700+ mg morphine equivalent cumulative dose Exceeded 10 or 30 day supply Initiated on a long-acting opioid Initiated on tramadol
44
What is the definition of tolerance?
The reduction of drug effect over time as a result of exposure to the drug
45
What is the definition of dependence?
When an abstinence syndrome occurs following administration of an antagonist drug or abrupt dose reduction or d/c of an opioid
46
What is the definition of addiction?
Ongoing substance use despite known harmful consequences to health or relationships
47
What is the definition of pseudoaddiction?
Person exhibits behaviors suggestive of addiction but in reality are a reflection of unrelieved pain
48
How long until a patient has physical and psychological opioid dependence?
Approximately 3 weeks of daily opioid use
49
What are the sx of WD after 3-4 hours of non-use?
Drug craving Anxiety Fear of WD
50
What are the sx of WD after 8-14 hours of non-use?
``` Anxiety Restlessness Insomnia Rhinorrhea Lacrimation Diaphoresis Stomach cramps Mydiasis ```
51
What are the sx of WD after 1-3 days of non-use?
``` Tremors Muscle spasms Vomiting Diarrhea Tachycardia Chills ```
52
What opioids can be given to treat acute WD?
Any
53
What is the new term for detoxification?
Medically supervised WD
54
What drugs should be used for detox?
Suboxone Buprenorphine Methadone
55
What medications can be used for sx relief in detox?
Clonidine Benzo Loperamide Anti-emetics
56
What is the length of time for drugs of abuse that can be detected in the urine?
About 48 hours
57
How do we evaluate a urine sample?
``` Appearance and color Temperature Volume Concentration of urine Urine pH, specific gravity, CrCl ```
58
What are the two types of urine tests?
Immunoassay | Gas chromatography-mass spectrometry (GC-MS)
59
What is the most common initial urine test?
Immunoassay
60
How does immunassay work?
Uses antibodies to detect the presence of parent drug or metabolites
61
What is a negative about immunoassays?
False positives can occur d/t other substances
62
If a patient's immunoassay tests positive, does that mean that they took something?
No, it is presumptive
63
When is the GC-MS used?
Confirmation purposes
64
Which test type is the most accurate and sensitive?
GC-MS
65
Why is GC-MS not used as often?
Time-consuming and costly
66
What are the s/sx of opioid overdose?
Decreased RR and bowel sounds Miosis Depressed mental status
67
What opioids can cause serotonin syndromes or seizures?
Meperidine | Tramadol
68
What opioids can cause hepatotoxicity?
APAP combinations
69
What opioids can cause QTc prolongation?
Methadone | Oxycodone
70
What is the management of opioid overdose?
ABCs Secure airway Administer naloxone Tox panel, CPK, electrolytes, glucose, ECG
71
What is the goal RR for naloxone administration?
12+ BPM
72
What are preventative techniques for opioid overdose?
Prescription Drug Monitoring Programs Abuse-deterant formulations (ER) Civilian access to naloxone

Pain (5 decks)

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