Lecture 5-6 Flashcards
Acute Pain
Why would we treat acute pain ?
↓ complications
● ↓ likelihood of acute-to-chronic pain conversion
● Improve outcome
○ ↑ speed of recovery → ↓ length of stay → ↓ health care costs
● ↑ patient satisfaction
● Make the period of disease accompanied by pain less unpleasant
● ↑ productivity
● ↑ quality of life
what are the renal consequences of poor pain management ?
higher risk of oliguria
urinary retention
what are the cardio consequences of poor pain management ?
tachycardia, HTN, high cardiac workload
what are the muscular consequences of poor pain management ?
muscle weakness and fatigue
What should be part of your pain assessment ?
SCHOLARE/ Pain Experience
Labs tet
Medical history
Red Flags
Current medications
What are the RED Flags for diagnosis ?
NIFTI
Fractures
Infections
cancer
Visceral Disease / GI disease
What are the PHARM options for acute pain ?
Aceteminophen
NSAIDS
Opioids
Others : Adjuvants
What is PRICE ?
Protection, Rest , Ice in the first 48hours, Compression , Elevation
may not be able to do all
What are the non-pharmacological Treatment?
Activity as tolerated ( some activity is good!)
● Physiotherapy, range of motion exercises
● External supports (e.g., bandages, tape, braces)
● Cold/heat therapy
● Massage, acupuncture
● Self-management education and support
What are the benefit of Non steroid analgesic ?
May not need opioids
even if they need opioids –> might not need as much
What is a true weak opioid ?
That is not entirely true, just need to pay attention to the dosing
What is a important DDI with acetaminophen ?
Warfarin
Can ↑ INR and would require more warfarin
What is the MAX dose of acetaminophen ?
4 g from ALL sources
if long term use or frail / bad liver ( alcoholic) ~ 3 g
What are the ADR from NSAIDs ?
GI
CV
Renal
CNS ( decrease the seizures threshold )
which of the NSAID has the highest risk of CV ?
Diclofenac
Which of the NSAID has the lowest risk of CV ?
Naproxen ~ more CV neutral
Which of the NSAIDs has the lowest GI risk?
Diclofenac/celecoxib
What is the MOA of Celecoxib + Diclofenac ?
COX2 inhibitor
What is the DDI between concurrent use of ASA and Ibuprofen ?
Ibuprofen causes steric hindrance to ASA binding and decreases ASA efficacy ( Cox1)
What is the DDI between concurrent use of ASA and Naproxen ?
Conformation change and can take ASA place
In terms of GI toxicity , rank the NSAIDS risk ?
High COX1 > non-selective NSAID > COX2
What are the risks factors for GI bleeds ?
Age >65
Comorbidities
High Doses of NSAID
Upper GI bleeds
H.pylori infection
Multiple use of NSAID
What is the relationship between COX1-2 , GI and CV risks ?
more COX1 ( like ASA) –> more GI risk
More Cox2 ( like diclo) –> more cv risks
If you have no risk of GI bleeds, recommended NSAID ?
non- selective : ibuprofen
If you have 1-2 risk of GI bleeds, recommended NSAID ?
COX2
non-selective+ PPI or misoprostol
If you have >2 risk of GI bleeds, recommended NSAID ?
Celecoxib + PPI or Misoprostol
Which of COX inhibition has higher risks of GI bleeds ?
COX1 - naproxen , ASA, Ketorolac
Which of COX inhibition has higher risks of CV bleeds ?
COX2 - Celecoxib, Dicofenac
What is the systemic absorption rate of TOPICAL NSAIDs ?
<6%
Can we use acetaminophen in pregnancy ?
Yes but short term ONLY
When can we use NSAIDs in pregnancy ?
Safer 16 weeks to 20 weeks for ORAL
Topical at any stages
Can a Breastfeeding mother use acetaminophen or NSAIDs ?
YEs, it is excreted in LOW concentrations
Can we use Opioids is Pregnancy ?
try to avoid ! Especially codeine, oxycodone
But can possibly try morphine, fentanyl and hydromorphone
Codeine is metabolised by which CYP ?
CYP2D6 –> has multiple polymorphism
could lead to ultra-rapid metablizers –> more risk of ADR
Mild pain - WHO analgesi ladder recommendation ?
Weakopiod , or non opioid or adjuvant tx
What is the CPOT ?
critical care pain Observation Tool –> used in ICU
observe pts in actions that would cause pain and after the use of analgesics
What is the ideal goal in RASS ?
0 –> alert and calm
assess delirium
Which of the opioids in better in ICU ?
Hydromorphone –> less effect on the kidneys, less histamine release
Why do we refrain from give fentanyl to ICU patients ?
highly lipophilic –> accumulation and prolonged sedation
What is the preferred way to manage pain pre-operation ?
multimodal , relieve pain and less need for opioids
how are pain medications managed after the surgery ?
ATC non-opioids ( think of gabapentinoids) , Opioids are short term , PCA or PRN
What do we need to know about PCA ?
lock interval, 4 hours limit
Goal = 1-3/10
NEVER for non-opioid naive and chronic pain
Wich Nsaid can be injected for post-op ?
Ketorolac ( 5-7 days)
What is incidental pain ?
predictable pain
