Management of Acute Post-operative Pain Flashcards
what did pain used to be believed to be?
-punishment from the goddess Poena (pain)
sensory experience secondary to tissue damage
nociception
- must have noxious stimulus
- ex. mechanical, thermal, chemical
Unpleasant sensory and emotional experience that arises from actual or potential tissue damage
pain
*ppl may experience pain BEFORE you touch them
what are the two causes of pain?
nociceptive (physical stimulus)
neuropathic (CNS damaged)
what are the two durations of pain?
- acute (know the cause and the end point)
- chronic (not sure what caused it or what will end it)
what things can cause inadequate control of acute pain
- anxiety
- inc symp output
- poor rest
- inadequate oral intake
what is the first part of the trigeminal pain pathway?
-noxious stimuli
- cell damage, chemical mediators released causing:
- -1rst order neuron impulse
- -peripheral nociceptors sensitized
where are 1rst order, second order, and third order neurons located in the trigeminal pain pathway?
1rst: periphery
2nd: spinal cord
3rd: brain
what are the types of analgesics that modulate the pain pathway and what do they do?
opioids and non-opioids:
- both act centrally and in the periphery
- interupt ascending nociceptive impulses (2nd and 3rd)
- depress impulse interpretation in CNS
what are the non-opioid analgesics?
- NSAIDS
- aspirins
- tylenol
how do NSAIDS work?
-supress arachidonic acid which supresses both COX-1 and COX-2 genes
what are the side effects of NSAIDS?
- GI toxicity
- dec renal function
- antiplatelet (like aspirin but not as intense)
- shunt activity to lipooxygenase
what is the big effect with NSAIDS and an asthema pt?
- NSAIDS shut down leukotrienes which drastically effect asthema pts
- ALWAYS ASK ASTHMATICS IF THEY TAKE IBUPROFEN!
what are the contraindications to NSAIDS?
- 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
what are COX-2 selective NSAIDS?
- they dont block COX-1 so they keep the good stuff
- protect normal physiologic processes
- anti-inflammatory, analgesic, antipyretic
*celecoxib is prime example
why dont we use COX-2 inhibitors exclusively?
- poor efficacy in 3rd molar model
- expensive
- only one option on market
- inc embolic phenomena
- contraindicated in sulfa allergy
how does acetominophen (tylenol) work?
- 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
how much acetominophen can your liver handle if you are healthy? questionable health?
healthy = 4g/d questionable = 2g/d
what are the opioid analgesics?
- oxycodone
- hydrodone
- codeine
- in that order of most potent to least
*good for pain relief but bad for dependence
what are the good effects of opioids?
- analgesia
- respiratory depression
- sedation
what are the side effects of opioids?
- euphoria
- dependence
- constipation
- dysphoria
*will not happen with our pts bc we would never prescribe for more than 3-5 days
what can you do to make opioids work better/
- the are SYNERGISTIC with tylenol
- reduces the amount of opioid required for analgesia
- acetominophen (tylenol) is the one that DICTATES dose/frequency
what must happen with oral opiates ?
synthetic oral opiates must be converted to active metabolites using cytochrome P450
*4-10% of caucasians are deficient
what is the mechanism of tramadol?
- weak binding at Mu
- inhibit incoming nociceptive impulses
is tramadol good for odontogenic pain?
NO
- proven efficacy for CHRONIC pain (not defined in acute pain)
- no more effective than codeine-acetominophen combinations
confusion regarding opioid use and fear of addiction can result in what?
under treatment of pain
what is tolerance?
- repeated doses elicit LESSER effect than initial dose
- in dose to attain desired effect
what is dependence?
- body PHYSIOLOGICALLY adapts to the effects of the drug
- sudden dec will produce withdrawl symptoms
what is the rule with addiction?
opioids do not produce addiction, pts produce addiction
*she said she wouldnt go to deep into this
what encompasses the pre-surgical eval of a pt?
- type of surgery and expected post-surgical pain
- pre-existing medical conditions and medications
- pts previous experiences
what is pre-emptive analgesia?
- give by mouth analgesics PRIOR to surgery
- this inhibits prostaglandin synthesis
- lessening nociception generated DURING procedure will reduce overall postop analgesic requirement
in the choice of analgesic, should you first prescribe opioid or non-opioids?
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
what should be the dosing frequecy of ibuprofen or any postop drug?
- prescribed around the clock on a fixed-dose schedule REGARDLESS OF PAIN SEVERITY
- “as needed” frequency leads to haphazard drug levels
when are opioids used as opposed to non-opioids?
used for “breakthrough” pain if the non-opioid regimen is OPTIMIZED
what is the first step in the stepped approach to prescribing postop meds?
STEP ONE
- ibuprofen 600mg q6hr
- acetaminophen 500-1000mg q6hrs
- these are synergistic
- wont overdue bc the mechanisms are different
what is the second step in the stepped approach to prescribing postop meds?
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
what are the rules for pregnant pts?
- LA: lidocaine even with epi is ok
- ANALGESIA:
- -no NSAIDS
- -use tylenol instead
- -narcotic use only with OBGYN approval
what are the rules for chronic opioid users?
*these are NOT the abusers
- post-op pain is IN ADDITION to baseline pain
- optimize daily opioid regimen
- tolerance may require temporary inc in opioid dosage
what are the rules for the rehabilitated users?
- discussion up front
- post-op pain control with NSAIDS
- ** NEVER prescribe a drug class that they have abused
when a pt has a reaction after being previously exposed to a drug
allergic reaction
- most of time they are adverse affects
- immune mediated
what are the S/S of allergic rxn?
- skin rash/hives
- wheezing
- swelling of body parts
- anaphylaxis
what is the tx of an allergic rxn if there is anaphylaxis?
THIS IS A MEDICAL EMERGENCY
- 911
- BLS
what is the tx of an allergic rxn if there is NO anaphylaxis?
- discontinue the drug
- antihistamines
- corticosteroids
a response that is usually unexpected, undesireable, and potentially harmful
adverse reactions
*ex. GI, Bronchospasm
what are the two most common opioid adverse reactions?
- nausea (25%)
- pruitis (10%) - itching
what are some strategies to avoid adverse reactions with opioids?
- dose reduction
- opioid rotation
- manage the adverse effects
when is the only time that Dr. Kennedy said she uses corticosteroids in dentistry?
-when she ext a tooth close to a nerve
how are corticosteroids used in dentistry?
- topical
- enteral (po) for edema
- non-anaphylactic allergic reactions that do not respond to antihistamines
what are the contraindications of corticosteroids?
- hx of chronic infection
- peptic ulcer disease
- diabetes mellitus (uncontrolled)
- poor wound healers
- cautions with simultaneous NSAID use
what is the rule of two’s with corticosteroids?
consider a stress (additional) dose of steroid if…
- 20mg prednisone per day for:
- -more than 2 weeks
- -in the past 2 months
