analgesia - Briana Nolan Flashcards
analgesia ladder
non selective NSAIDs
ibuprofen
naproxen
aspirin
indometacin
COX-2 selective NSAIDs
celecoxib (oral)
parecoxib (IV only)
what do non selective NSAIDs target
COX 1 and 2
which are present in the GI mucosa, kidney and cardiovascular system
what are COX-2 inhibitors less likely to cause
less likely to causes peptic ulcers as COX-2 is not present in the GI mucosa
what do COX enzymes do
cyclooxygenase
breakdown of arachadonic acid to prostaglandins, prostacyclins and thromboxane
limits inflammation, pain and fevers
contraindications of NSAIDs
pregnancy, category C (tocolytic, causes premature closure of ductus arteriosus)
known gastric ulceration
renal impairment
atypical opoid agonists
tramadol (oral/IV)
tapentadol (oral)
act on opioid receptors as well as other receptors
what does tramadol act on
also noradrenaline and serotonin reuptake inhibitor
giving this to a patient who is also on antipsychotics or antidepressant may cause serotonin syndrome
full opioid agonists
oxycodone (oral)
codeine
morphine
fentanyl, alfentanyl, remifentanyl
hydromorphone
methadone
strong mixed opioid agonist/antagonist
buprenorphine (sublingual, patch)
what kinds of opioids can you prescribe together
you can prescribe a strong opioid and an atypical but never two strong together
what are the IV strong opioid options
morphine
fentanyl/alfentanyl/remifentanyl
hydromorphine
what is required when prescribing strong IV opioids
requires close monitoring, therefore only given in controlled environments eg. theatre, recovery, ED
never given on the PRN chart in the ward
all are commonly prescribed in theatre and recovery
morphine and fentanyl are commonly prescribed in ED for severe pain
tapentadol dose
IR for PRN: 50-100mg PRN up to every 4 hours, 400mg maximum dose
as a regular medication: PO tapentadol SR 50 or 100mg BD
tramadol dose
IR for PRN: 50-100mg PRN up to every 4 hours, 400mg maximum dose
as a regular medication: PO SR 50 or 100mg BD
oxycodone PRN dose
PO 2.5-10mg PRN up to every 2 hours, 20-60mg maximum dose
Buprenorphine PRN dose
sublingual buprenorphine 200-400microg PRN up to every 4 hours, 1600microg maximum dose
preferred agent in renal impairment as hepatic ally metabolised and mainly excreted via bile
options for strong opioid as regular medications
Targin (oxycodone/naloxone) SR tablets
buprenorphine tablets
only prescribe 1 slow release opioid and have a plan to review within the week, unless under guidance of a senior
common side effects of opioids
drowsiness
constipation
respiratory depression
for any patient on methadone or high opioid doses pre-admission, have a low threshold to contact the acute/chronic pain service
patient controlled analgesia (PCA)
must be alert enough to comprehend and physically press the button
maximum doses are input into the machine with lockout periods
prescribed by anaesthetists or acute pain service for ongoing or expected severe pain
typically either IV hydromorphone or fentanyl
alternative analgesia options
anti convulsants: pregabalin/gapapentin
alpha agonists: clonidine/dexmedetomidine
ketamine
what kind of pain are anticonvulsants good for
typically for nerve pain
what might you do for a NOF patient to reduce systemic analgesia requirement
generally a femoral/fascial iliac nerve block whilst in ED to reduce the systemic analgesia requirement
