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Pharm 2 final > Management of Acute Postoperative Pain > Flashcards

Management of Acute Postoperative Pain Flashcards

1
Q

according to International Association for

the Study of Pain, what is the definition of pain?

A

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

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2
Q

types of causality of pain

A
  1. nociceptive

2. neuropathic

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3
Q

what type of pain do we normally tx in dentistry?

A

acute nociceptive pain

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4
Q

inadequate management of acute pain may cause what?

A
  1. anxiety
  2. increased sympathetic output
  3. poor rest
  4. inadequate oral intake
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5
Q

noxious stimulus causes cell damage and what to release?

A

chemical mediators

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6
Q

what happens when chemical mediators are released after a noxious stimulus?

A
  1. 1st order neuron impulse

2. peripheral nociceptors sensitized

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7
Q

what modulates the trigeminothalamic tract pathway?

A

opioids and non-opioids

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8
Q

how does analgesics modulate the trigeminothalamic tract pathway?

A
  1. by interrupting ascending nociceptive impulses

2. depressing impulse interpretation in CNS

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9
Q

what does NSAIDs block?

A

cyclooxygenases which activates prostaglandins that cause pain, inflammation and fever

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10
Q

common side effect of traditional NSAIDs

A
  1. stomach pain

2. heartburn

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11
Q

serious side effect of traditional NSAIDs

A
  1. GI toxicity

2. decreased renal fxn

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12
Q

why is traditional NSAIDs a relative contraindication for asthmatic patients?

A

shunt activity to lipoxygenase

if asthmatic pt takes ibuprofen, cyclooxygenase is inhibited –> activity has to go somewhere so goes towards lipoxygenase pathway –> a lot of leukotrienes are created which induces broncospasm and asthmatic rxns

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13
Q

absolute contraindications to NSAIDs

A
  1. allergy
  2. pregnancy
  3. erosive or ulcerative conditions of the GI mucosa
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14
Q

relative contraindications to NSAIDs

A
  1. asthma
  2. anticogulant therapy or hemorrhagic disorders
  3. compromised renal fxn
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15
Q

example of COX-2 selective NSAID

A

celecoxib (celebrex)

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16
Q

effect of celecoxib (celebrex)

A
  1. anti-inflammatory
  2. analgesic
  3. anti-pyretic
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17
Q

T/F: celecoxib (celebrex) protects normal physiologic processes

A

true

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18
Q

COX-2 activates what?

A
  1. prostaglandins

2. prostacyclin

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19
Q

effect of prostaglandins when activated by COX-2

A
  1. pain, inflammation, fever

2. renal fxn

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20
Q

effect of prostacyclins when activated by COX-2

A
  1. platelet inhibition

2. vasodilation

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21
Q

effect of prostaglandins when activated by COX-1

A
  1. gastric mucosal barrier

2. renal fxn

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22
Q

effect of thromboxane A2 when activated by COX-1

A
  1. platelet aggregation

2. vasoconstriction

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23
Q

why don’t we use COX-2 inhibitors exclusively to manage acute postoperative pain?

A
  1. poor efficacy in 3rd molar model
  2. expensive since it’s the only one option on the market
  3. increased embolic phenomena
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24
Q

when is COX-2 inhibitors contraindicated?

A

pts with sulfa allergy

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25
Q

mechanism of action of acetaminophen

A

believed to be prostaglandin synthesis inhibition in CNS

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26
Q

what are the effects of acetaminophen?

A
  1. analgesic

2. anti-pyretic

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27
Q

T/F: acetaminophen has anti-inflammatory effects

A

FALSE

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28
Q

which organ conjugates acetaminophen into non-toxic metabolites?

A

liver

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29
Q

what dosage can the liver no longer conjugate acetaminophen into non-toxic metabolites?

A

200-250 mg/kg/24 hr

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30
Q

what cyctochrome breaks down acetaminophen?

A

P450

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31
Q

what is the toxic acetaminophen metabolite?

A

NAPQI (N-acetyl-p-benzo-quinone imine)

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32
Q

what is the recommended daily maximum of acetaminophen by the FDA? by McNeil Consumer Healthcare (ppl that make Tylenol)?

A

FDA - 4000 mg/day

McNeil Consumer Healthcare - 3000 mg/day

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33
Q

what is the daily maximum amount of acetaminophen that patients with confirmed or suspected liver disease can take?

A

2000 mg/day

34
Q

effects of opioids on mu and kappa receptors

A
  1. analgesia (mu >kappa)
  2. respiratory depression
  3. sedation
35
Q

other effects of opioid on mu receptor

A
  1. euphoria
  2. dependence
  3. constipation
36
Q

other effects opioids have on kappa receptors

A

dysphoria/psychomimetic

37
Q

codeine, hydrocodone, and oxycodone are what type of agonists?

A

semi-synthetic opiate receptor agonists

38
Q

codeine, hydrocodone, and oxycodone differ in what?

A

potency

39
Q

rank potency of codeine, hydrocodone, and oxycodone

A

oxy > hydro > codeine

40
Q

codeine, hydrocodone, and oxycodone have synergistic effect when combined with what?

A

acetaminophen

41
Q

codeine, hydrocodone, and oxycodone combined with acetaminophen reduces what?

A

amount of opioid required for analgesis

42
Q

what dictates dose/frequency when codeine, hydrocodone, and oxycodone in combo with acetaminophen?

A

acetaminophen

43
Q

synthetic oral opiates must be converted into what?

A

active metabolites

44
Q

how are synthetic oral opiates converted to active metabolites?

A

by cytochrome P450 CYP2D6

45
Q

active metabolite of codeine

A

morphine (effect entirely from metabolite)

46
Q

active metabolite of hydrocodone

A

hydromorphone (effect from parent drug and metabolite)

47
Q

active metabolite of oxycodone

A

oxymorphone (effect almost entirely from parent drug)

48
Q

what percent of caucasians are cytochrome p450 CYP2D6 deficient?

A

4-10%

49
Q

pentazocine has analgesic effect on which opioid receptor?

A

kappa

50
Q

pentazocine has antagonistic effect on which opioid receptor?

A

mu

51
Q

how does tramadol havea central dual mechanism of action?

A
  1. weak binding at mu

2. inhibit incoming nociceptive impulses

52
Q

tramadol has proven efficacy for what?

A

chronic pain

53
Q

tramadol is no more effective than what?

A

codeine-acetaminophen combo

54
Q

dentoalveolar surgery causes acute, post-operative mild-moderate pain lasting how long?

A

3-5 days

55
Q

why give pre-operative analgesics prior to surgery?

A

inhibits prostaglandin synthesis therefore lessening niciception generated during procedure will reduce overall postop analgesic requirement

56
Q

why give pre-operative local anesthetic before surgery?

A
  1. blockage of nociceptive input to CNS
  2. decreases central hyperexcitability
  3. less pain and analgesic intake at 4h and 48hr
  4. easier to maintain pain free state
57
Q

T/F: non-opioids analgesics have superior efficacy than opioids for post-op dental pain relief

A

true

58
Q

what is the go to for non-opioid analgesic?

A

ibuprofen

59
Q

why is ibuprofen the go to NSAID?

A
  1. unsurpassed efficacy
  2. low side effect profile
  3. low cost
60
Q

what is the only option when NSAID is contraindicated?

A

tylenol

61
Q

NSAIDs have what type of effect?

A

ceiling effect so higher doses needed to achieve anti-inflammatory effects

62
Q

why is non-narcotic analgesics prescribed around the clock on a fixed-dose schedule regardless of pain severity?

A

stable drug levels are attained

63
Q

dosage of ibuprofen

A

600 mg q6h

64
Q

maximum/day for ibuprofen

A

3200 mg

65
Q

dosage of acetaminophen

A

650 mg q6h or 500 mg q6h

66
Q

maximum/day for acetaminophen for healthy pt

A

3000 mg

67
Q

maximum/day for acetaminophen for pt with liver issues

A

2000 mg

68
Q

when are opioids indicated when managing moderate-severe pain?

A

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

69
Q

codiene + acetaminophen dosages

A

tylenol 2 = 15
tylenol 3 = 30
tylenol 4 = 60

70
Q

norco

A

hydrocodone and acetaminophen

71
Q

dosage of norco

A

5/325

72
Q

percocet

A

oxycodone and acetaminophen

73
Q

dosage of percocet

A

5/325

74
Q

stepped approach to managing acute postoperative pain

A
  1. ibuprofen 600 mg q6h and acetaminophen 650 mg q6h

2. norco 5/325 1 tab q6h prn OR percocet 5/325 1 tab q6h PRN

75
Q

maximum number of opioids prescribed for adults

A

7 days

76
Q

maximum number of opioids prescribed for minors

A

5 days

77
Q

opioids can’t be prescribed if dosing is greater than what?

A

> 30mg morphine equivalent dose (MED) over prescribed period

78
Q

when is it best to treat pregnant patients?

A

2nd trimester

79
Q

can pregnant patients have lidocaine?

A

yes

80
Q

T/F: pregnant patients can be given NSAIDs to manage pain

A

FALSE! no NSAIDs

81
Q

what can be given to pregnant patients in pain?

A

Tylenol and narcotic with OB approval

Pharm 2 final (10 decks)

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