Choosing an analgesic Flashcards
acute pain
frequently has a known cause
has identifiable tissue damage
usually subsides as healing takes place
has a predictable endpoint
associated with anxiety – flight or fight and increase in pulse and respiratory rate
chronic pain
present in area for greater than 3 months
does not usually manifest the physiologic arousal as seen in acute pain
may exhibit reactive depression and decreased function
physiological condtiions associated with chronic pain
why?
high prevelance of psychological comorbitites among patients with chronic pain
presence of chronic pain may cause emoional distress and exacerabate premorbid psychological disorders
mood disorders anxiety disorders somatic symptoms disorders personality disorders other conditions
- unidentified can get in way of achieving management
three main minsconceptions regarding pain and analgesics
- patients who are in pain always have observable signs
- obvious pathology, test results, and the type of surgery determine the extence and the intensity of pain
3, patients should wait as long as possible before taking a pain medication. this period of abstinence will teach them to have a better tolerance for pain
three main minsconceptions regarding pain and analgesics
- patients who are in pain always have observable signs
- obvious pathology, test results, and the type of surgery determine the extence and the intensity of pain
3, patients should wait as long as possible before taking a pain medication. this period of abstinence will teach them to have a better tolerance for pain
post op pain mangament with aspirin
650 mg better than placebo or 30 mg codeine
post op pain mangament with aspirin
650 mg better than placebo or 30 mg codeine
adult ibuprofen rx
200-800 mg
q 6 hrs
no excees 3.2 g/day
downfalls of the COX -2 selective
resulted in increase in MI’s and strokes, especially with rofecoxib and valde
COX-2 on the market
celecoxib
head injuries give opoids
no
head injuries give opoids
no
combination analgesics
opiod with non opiod
amount of drug in combination analgesics determined by
amount of the non-opiod analgesic
pharmacologic control of pain can b direced at any of the three nocieptive processes
- initiation of impulses
- free nerve endings - propagation of those impulses
- like local anesthetic - perception of the painful stimuli
- like narcotics
hydrocodone associated with
vicodine
complete agonist (opiod)
oxycodone associated with
percocet
complete agonsit - opiod
NSAIDs act where
at site of the initiation of nociceptive impulses
primarily in periphery by preventing synthesis and release of inflammatory mediators
aspirin like drugs effect
acetylsalicyclic acid moiety binds irreversibly to platalet cyclooxygenases
prevents platelet production of prostaglandins and thromboxanes - which are essential for platalet aggregation
6 main indications for aspirin like drugs
- mild to moderate pain
- fever
3/ arthritis
4/ thromboemolic disorders - TIAs
- postmyocardial infarction
contraindications and side effects of aspirin like drugs
- alergic
- anti-coagulated patient
- gastric ulcers
- side effects such as
- epigastric distress
- nausea / vomit
- increased bleeding time
reyes syndrom from
aspirin given to young children resulting in encephalopathy and liver disease
aspirin dose effetive after extraction
650 mg vs 30 mg of codeine or placebo
ibuprofen is
peak?
half life?
motrin / advil
peal is 1-2 hr
half life 2-4
adult vs children dose of ibuprofen
200-800 mg q 6 hr
- not exceed 3.2 grams / day
2-11 yrs.
7.5 mg/ kg qid
not exceed 30 mg/kg/day
naproxen sodium
dosage?
naproxen dosage
safe for short use
similar to ibuprofen
slightly slower onset but longer duration
may consider before night before surgery
loading dose of 550 mg - then 275 mg q6-8 hr. not exceeding 1375 mg/day
naproxen = 250-500 mg bid
not exceed 1g/day
prostaglandins usually used for? implication
responsible for producing compounds that protect gastric lining
- so inhibiting them with NSAIDS - can see most common side effects of
- gastrointestinal problems - dyspepsia, gastric erosions, and mucosal ulcerations
NSAID that effects bleeding
ASA - only one because it IREVERSIBLY inhibits the COX pathways
- prolongs bleeding
dosage of celecoxib aka
celebrex
COX-2 inhibitor
100 or 200 mg BID
pregnency use of NSAIDs
avoid when? why?
APAP > ASA
apap – therapeutic doses is generally considered best choice for manging acute pain
ASA – can lead to anemia and delivery cmplications and postpartum hemorrhage
avoid ASA and NSAIDs in THIRD TRIMESTER
- inhibit prostaglandin syntheiss and can inhibit contractions in labor
- constriction of ductus arteriosis in utero – pulmonary HTN of newborn
-
NSAIDs and alcohol - general
combo increases the risk of fecal blood loss associated with GI erosions and ulcers
acetaminophen aka ?
metabolite of?
tylenol
metabolite of phenatecin – equipotent to ASA but fewer side effects b/c acts more centrally – weak inhibitor of the peripheral prostaglandins
no / minimal antiinflammatory NSAID
APAP - acetaminophen / tylenol / panadol
hepatic / liver toxicity in which NSAID
dose?
acetaminophen – induced with APA with daily dose of 4000mg is exceeded
so daily dose is 3000 mg max or 3 g / day
acetaminophen dose with opiods
max of 325 mg
indications for acetaminophen
mild to moderate pain
fever
contraindications for acetaminophen /
hypersensitivityy
precautions
- hepatic / liver disease
- renal disease
- chronic alcoholism
acetaminophen dosage
325-650 mg q4 h
not to exceed 3gm / day
LA’s working where
blocking propagation at peripheral site so do not reach spinal cord or brain
opiods receptors are where
spinal cord, medulla, and periaqueductal grey matter (considered important areas in perception of pain)
- decrease the perception of pain in the CNS
contraindications for opiods
hypersensitivirt
CHRONIC OROFACIAL PAIN - NO
head injuries - NO
first pass addect in centrally acting analgesics
50 to 90% of the absorbed drug is metabolized on the first pass through the liver – clinically this means that only one-tenth to one-half of the dose reaches the analgesic receptors in the brain
codeine is
tylenol #3
most important for choosing regimen for pain control
cause of pain and pain severity
important use of LA
perioperative LONG ACTING LA can delay onset of post procedural pain
long acting LA
bupivacaine - marcaine
exparel – liposomal bupivacaine – injected into SURGICAL site - not for use of 18 year or younger
major differences between non-opioid and opioid
non opioid
- ceiling effect to anagesia (no ceiling effect on analgesic response)
-no toleranc or physical dependence built
- are antipyretic
=- posses antinflamm + analgesic (except acetaminophen )
If use opioid should be
FULL agonist with minimal first pass affect
dosing equivalaents of oxy, hydroco, codeine and tramadol
5mg of oxycodone = 10 mg of hydrocodone = 65 mg of codeine = 75 mg tramadol
source of diversion
non used drugs - then used for nonmedical use by those around - not prescribed
max dos of acetaminophen
3 grams aily
325-650 po - q4-6 hours
or 1 g po 3x day
percocet is?
dosing?
5/325
acetaminophen 325 mg
oxycodone = 5mg
12 tablets usually q 6 hr
vicodin is?
dosing?
acetaminophen 300 mg
hyrocodone 5 mg
15 tabs usually q 6
vicoprofen is?
dose?
hydrocodone bitartrate 7.5 mg
ibuprofen 200 mg
15 tabs 4-6 hr prn pain
potential drug interactions with motrin
motrin = ibuprofen
antihypertensive - may decrease effectivenes
ASA, corticosteroids - increased risk of adverse GI reactions
Digoxin, lithium , oral anti-coagulants- may incease the plasma levels or affects of these medications
methotrexate – decreased clearance and thus increased toxicity
gastric bypass probably not giving?
NSAID
or esophagial reflux
