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Pharm II > Management of Acute Post-operative Pain > Flashcards

Management of Acute Post-operative Pain Flashcards

1
Q

what did pain used to be believed to be?

A

-punishment from the goddess Poena (pain)

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2
Q

sensory experience secondary to tissue damage

A

nociception

  • must have noxious stimulus
  • ex. mechanical, thermal, chemical
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3
Q

Unpleasant sensory and emotional experience that arises from actual or potential tissue damage

A

pain

*ppl may experience pain BEFORE you touch them

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4
Q

what are the two causes of pain?

A

nociceptive (physical stimulus)

neuropathic (CNS damaged)

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5
Q

what are the two durations of pain?

A
  • acute (know the cause and the end point)

- chronic (not sure what caused it or what will end it)

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6
Q

what things can cause inadequate control of acute pain

A
  • anxiety
  • inc symp output
  • poor rest
  • inadequate oral intake
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7
Q

what is the first part of the trigeminal pain pathway?

A

-noxious stimuli

  • cell damage, chemical mediators released causing:
  • -1rst order neuron impulse
  • -peripheral nociceptors sensitized
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8
Q

where are 1rst order, second order, and third order neurons located in the trigeminal pain pathway?

A

1rst: periphery
2nd: spinal cord
3rd: brain

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9
Q

what are the types of analgesics that modulate the pain pathway and what do they do?

A

opioids and non-opioids:

  • both act centrally and in the periphery
  • interupt ascending nociceptive impulses (2nd and 3rd)
  • depress impulse interpretation in CNS
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10
Q

what are the non-opioid analgesics?

A
  • NSAIDS
  • aspirins
  • tylenol
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11
Q

how do NSAIDS work?

A

-supress arachidonic acid which supresses both COX-1 and COX-2 genes

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12
Q

what are the side effects of NSAIDS?

A
  • GI toxicity
  • dec renal function
  • antiplatelet (like aspirin but not as intense)
  • shunt activity to lipooxygenase
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13
Q

what is the big effect with NSAIDS and an asthema pt?

A
  • NSAIDS shut down leukotrienes which drastically effect asthema pts
  • ALWAYS ASK ASTHMATICS IF THEY TAKE IBUPROFEN!
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14
Q

what are the contraindications to NSAIDS?

A
  • allergy
  • pregnancy
  • erosive or UC of the GI mucosa
  • asthema (ask them if they can tolerate it)
  • anticoagulant therapy or hemorrhagic disorders
  • compromised renal fxn
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15
Q

what are COX-2 selective NSAIDS?

A
  • they dont block COX-1 so they keep the good stuff
  • protect normal physiologic processes
  • anti-inflammatory, analgesic, antipyretic

*celecoxib is prime example

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16
Q

why dont we use COX-2 inhibitors exclusively?

A
  • poor efficacy in 3rd molar model
  • expensive
  • only one option on market
  • inc embolic phenomena
  • contraindicated in sulfa allergy
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17
Q

how does acetominophen (tylenol) work?

A
  • believed to be prostaglandin synthesis inhibition in the CNS
  • is an analgesic and anti-pyretic (reduce fever)
  • DOES NOTHING for inflammation
  • none of the side effects seen with NSAIDS (COX-1) but can poison the liver (NIH is leading cause of acute liver failure)

*if cant give NSAIDS (asthematic) then give tylenol

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18
Q

how much acetominophen can your liver handle if you are healthy? questionable health?

A 
healthy = 4g/d
questionable = 2g/d
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19
Q

what are the opioid analgesics?

A
  • oxycodone
  • hydrodone
  • codeine
  • in that order of most potent to least

*good for pain relief but bad for dependence

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20
Q

what are the good effects of opioids?

A
  • analgesia
  • respiratory depression
  • sedation
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21
Q

what are the side effects of opioids?

A
  • euphoria
  • dependence
  • constipation
  • dysphoria

*will not happen with our pts bc we would never prescribe for more than 3-5 days

22
Q

what can you do to make opioids work better/

A
  • the are SYNERGISTIC with tylenol
  • reduces the amount of opioid required for analgesia
  • acetominophen (tylenol) is the one that DICTATES dose/frequency
23
Q

what must happen with oral opiates ?

A

synthetic oral opiates must be converted to active metabolites using cytochrome P450

*4-10% of caucasians are deficient

24
Q

what is the mechanism of tramadol?

A
  • weak binding at Mu

- inhibit incoming nociceptive impulses

25
Q

is tramadol good for odontogenic pain?

A

NO

  • proven efficacy for CHRONIC pain (not defined in acute pain)
  • no more effective than codeine-acetominophen combinations
26
Q

confusion regarding opioid use and fear of addiction can result in what?

A

under treatment of pain

27
Q

what is tolerance?

A
  • repeated doses elicit LESSER effect than initial dose

- in dose to attain desired effect

28
Q

what is dependence?

A
  • body PHYSIOLOGICALLY adapts to the effects of the drug

- sudden dec will produce withdrawl symptoms

29
Q

what is the rule with addiction?

A

opioids do not produce addiction, pts produce addiction

*she said she wouldnt go to deep into this

30
Q

what encompasses the pre-surgical eval of a pt?

A
  • type of surgery and expected post-surgical pain
  • pre-existing medical conditions and medications
  • pts previous experiences
31
Q

what is pre-emptive analgesia?

A
  • give by mouth analgesics PRIOR to surgery
  • this inhibits prostaglandin synthesis
  • lessening nociception generated DURING procedure will reduce overall postop analgesic requirement
32
Q

in the choice of analgesic, should you first prescribe opioid or non-opioids?

A

non-opioids

  • most post op dental pain has an inflammatory component
  • analgesic efficacy superior to opioids
  • ibuprofen is the go to for non-opioids
  • *tylenol is the only option when ibuprofen is contraindicated
33
Q

what should be the dosing frequecy of ibuprofen or any postop drug?

A
  • prescribed around the clock on a fixed-dose schedule REGARDLESS OF PAIN SEVERITY
  • “as needed” frequency leads to haphazard drug levels
34
Q

when are opioids used as opposed to non-opioids?

A

used for “breakthrough” pain if the non-opioid regimen is OPTIMIZED

35
Q

what is the first step in the stepped approach to prescribing postop meds?

A

STEP ONE

  • ibuprofen 600mg q6hr
  • acetaminophen 500-1000mg q6hrs
  • these are synergistic
  • wont overdue bc the mechanisms are different
36
Q

what is the second step in the stepped approach to prescribing postop meds?

A

STEP TWO

  • HC/APAP 5/325 1 tab q4hr PRN
  • OC/APAP 5/325 1 tab q4hr PRN

*come on pretty quick and go away quickly

37
Q

what are the rules for pregnant pts?

A
  • LA: lidocaine even with epi is ok
  • ANALGESIA:
  • -no NSAIDS
  • -use tylenol instead
  • -narcotic use only with OBGYN approval
38
Q

what are the rules for chronic opioid users?

*these are NOT the abusers

A
  • post-op pain is IN ADDITION to baseline pain
  • optimize daily opioid regimen
  • tolerance may require temporary inc in opioid dosage
39
Q

what are the rules for the rehabilitated users?

A
  • discussion up front
  • post-op pain control with NSAIDS
  • ** NEVER prescribe a drug class that they have abused
40
Q

when a pt has a reaction after being previously exposed to a drug

A

allergic reaction

  • most of time they are adverse affects
  • immune mediated
41
Q

what are the S/S of allergic rxn?

A
  • skin rash/hives
  • wheezing
  • swelling of body parts
  • anaphylaxis
42
Q

what is the tx of an allergic rxn if there is anaphylaxis?

A

THIS IS A MEDICAL EMERGENCY

  • 911
  • BLS
43
Q

what is the tx of an allergic rxn if there is NO anaphylaxis?

A
  • discontinue the drug
  • antihistamines
  • corticosteroids
44
Q

a response that is usually unexpected, undesireable, and potentially harmful

A

adverse reactions

*ex. GI, Bronchospasm

45
Q

what are the two most common opioid adverse reactions?

A
  • nausea (25%)

- pruitis (10%) - itching

46
Q

what are some strategies to avoid adverse reactions with opioids?

A
  • dose reduction
  • opioid rotation
  • manage the adverse effects
47
Q

when is the only time that Dr. Kennedy said she uses corticosteroids in dentistry?

A

-when she ext a tooth close to a nerve

48
Q

how are corticosteroids used in dentistry?

A
  • topical
  • enteral (po) for edema
  • non-anaphylactic allergic reactions that do not respond to antihistamines
49
Q

what are the contraindications of corticosteroids?

A
  • hx of chronic infection
  • peptic ulcer disease
  • diabetes mellitus (uncontrolled)
  • poor wound healers
  • cautions with simultaneous NSAID use
50
Q

what is the rule of two’s with corticosteroids?

A

consider a stress (additional) dose of steroid if…

  • 20mg prednisone per day for:
  • -more than 2 weeks
  • -in the past 2 months

Pharm II (16 decks)

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