Analgesia

Question 1

The pain ladder:

There are 5 steps:

What are they?

What should be done if their pain isn’t being controlled at the top of the pain ladder?

Answer 1

Regular paracetamol

+ Regular NSAIDs

+ PRN weak opioid

+ Regular weak opioid + consider PRN strong opioid

+ Regular + PRN strong opioids

Refer them to the pain service

Question 2

Step 1 - Simple Analgesia:

Give some examples? - 2

Step 2- Weak opioids:

Give some examples? - 3

Answer 2

NSAIDs
Paracetamol

Codeine
Dihydrocodeine
Tramadol

Question 3

Step 3 - Strong opioids:

Morphine:
- What formulations is it available in?

Oxycodone:
- What patient is this better in compared to morphine?

Buprenorphine:
- What drug addiction is this used in?

Hydromorphone and fentanyl are also used!!!

Pethidine - what is this opioid used in?

Answer 3

Tablet
Liquid
IV

Kidney impairment

Heroin addiction - methadone is also used

Obstetric

Question 4

NSAIDs:

It works because it inhibits the COX enzyme, reducing the formation of prostaglandins and thromboxanes, which are key inflammatory mediators!

Give some examples? - I, D, N, A, C, P

What needs to be given in conjunction?

Answer 4

Ibuprofen 
Diclofenac 
Naproxen
Aspirin 
Celecoxib
Parecoxib 

PPI for ulcer protection

Question 5

NSAIDs:

Why does it increase the risk of PUD?

GI side effects?

What can it cause in the blood?

Renal:

• What can it cause acutely?
• Why does it cause hyponatraemia?

What can it cause in the lungs, especially in those with lung disease?

Answer 5

Due to the reduction in prostaglandins, a protective factor in GI mucosa

Abdo pain
D&V

Platelet dysfunction (which could lead to intracranial haemorrhage)

AKI

The mechanism by which NSAIDs cause hyponatremia is the reduction of renal prostaglandins. Prostaglandins exert inhibition on the activity of the antidiuretic hormone; thus their reduction can cause free water retention (13) and hyponatremia.

BRONCHOSPASM
Nonsteroidal anti-inflammatory drugs (NSAIDs) can cause bronchospasm and trigger asthma exacerbations, presumably by increasing leukotriene production due to cyclooxygenase-1 isoenzyme inhibition.

Question 6

Paracetamol:

What routes can it be given in? - 4

Under what weight does the dose need to be reduced?

Answer 6

PO
PO
IV
NG

<50 kg - that is why children only take half a tablet!

Question 7

Morphine:

What is the liquid form of morphine called?

What is the medical name of the drug heroin which can come in a powder form?

What needs to monitored while on morphine?

Answer 7

Oramorph

Diamorphine

Kidney function

Question 8

Opioid overdose:

What are the signs of overdose:

• Resp
• Brain
• What will witnesses observe?
• What happens to the pupils?
• What does the patient experience is considered a psychiatric problem?
• What happens to the muscles?

What is given to counteract the overdose?

Answer 8

Rhabdomyolysis

Reduced RR

Reduced level of consciousness

Myoclonic jerks in mild overdose

Pupillary constriction (miosis)

Hallucinations

Naloxone IV - infusion