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Pharmacology 680 > neuraxial opioids > Flashcards

neuraxial opioids Flashcards

1
Q

outside the dura, can have a sensory block - a motor block - or both

A

epidural anesthesia

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2
Q

directly in CSF - quick side of effect

A

subarachnoid

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3
Q

what is the point of ERAS protocols?

A

to decrease amount of opioids being used by moving towards multimodal administration of meds

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4
Q

what is receptor distribution in spinal cord

A 
All three (mu, kappa, delta) are present in high 
concentrations in the dorsal horn of the spinal concentrations in the dorsal horn of the spinal Cord
-gelatinosa mainky mu
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5
Q

where else are mu receptors found in spinal?

A

substantia gelatinosa

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6
Q

a grey matter structure of the dorsal spinal cord primarily involved in the transmission and modulation of pain, temperature, and touch

A

substantia gelatinosa

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7
Q

what requires a higher dose of neuroaxial opioids?

A

epidural dose 5-10X subarachnoid dose

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8
Q

dose of morphine epidural vs subarachnoid:

A

epidural dose up to 5 mg

- spinal dose 0.25 – 1 mg

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9
Q

what type of pain are neuroaxial opioids best for?

A

visceral (organ) pain

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10
Q

MOA of Opioids placed in the epidural space

A

diffuse
across the dura to affect mu receptors on
the spinal cord AND are absorbed to
produce the effects like IV opioids

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11
Q

what opioid has slower onset in epidural space and why?

A

morphine because of lower lipid solubility so will have an increase in duration

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12
Q

what opioids will absorb more systematically?

A

fentanyl and sufentanil r/t higher lipid solubility

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13
Q

Fentanyl – CSF peak concentration

A

20 mins

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14
Q

Sufentanil – CSF peak concentration

A

6 mins

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15
Q

Morphine – CSF peak concentration

A

1-4 hours

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16
Q

what % of morphine epidural dose enters CSF?

A

3%

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17
Q

how are epidural opioids absorbed?

A

via the extensive venous plexus

in the epidural space

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18
Q

Fentanyl – peak blood conc epidural administration

A

5-10 mins

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19
Q

Sufentanil - peak blood conc epidural admin

A

<5 mins

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20
Q

Morphine - peak blood conc epidural admin

A

10-15 mins

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21
Q

how can absorption be decreased with epidural opioids?

A

add epinephrine to mixture: the epi vasoconstricts the venous plexus

22
Q

does epinephrine affect the diffusion across the dura?

A

NO

23
Q

what happens when epinephrine and morphine is injected into subarachnoid space?

A

the analgesia is enhanced compared to injection

of morphine alone.

24
Q

duration of epidural fent?

A

50-100 mcg – lasts 1-3 hours

25
Q

duration of epidural morphine

A

2-5 mg – lasts 4-24 hours

this is scary bc SE could last this long!

26
Q

how does Higher lipid solubility affect mvmt of opioids in epidural space?

A

limits the movement cephalad as the

drug is taken up by the spinal cord

27
Q

how does lower lipid solubility affect mvmt of opioids in epidural space?

A

allows longer
time in the CSF and movement cephalad
(think morphine)

28
Q

what two things effect mvt of epidural opioids cephalad?

A

coughing and increase in pressure (straining)

NOT BODY MVMT

29
Q

4 classic side effects of neuroaxial opioids?

A

pruritus
nausea and vomiting
urinary retention
Resp depression

30
Q

most COMMON side effect of neuraxial opioids?

A

pruritis

31
Q

MOA of pruritis with neuraxial opioids

A

Likely due to opioids in CSF moving up to interact with OR in the trigeminal nucleus

32
Q

what type of patients does pruritis affect more and why?

A

OB pts due to estrogen

33
Q

treatment of pruritis? (3)

A

-Opioid antagonist like Narcan
– Antihistamines
– Gabapentin

34
Q

type of patients that urinary incontinence is more prevelant?

A

young males

35
Q

what is urinary retention caused by?

A

interaction of opioid with opioid
receptors of the sacral spinal cord

inhibition of sacral parasympathetic outflow causing
detrusor muscle relaxation, increased bladder capacity

36
Q

treatment of urinary retention?

A

narcan

37
Q

With epidural morphine, how long can urinary retention last?

A

15 mins of admin to 16 hrs

38
Q

describe the onset of ventilatory depression with neuraxial morphine

A

unpredictable and delayed - may be within minutes or 6-12 hours after
affects receptors in ventral medulla

39
Q

describe onset of ventilatory depression with neuraxial fent and sufent

A

within 2 hours due to systemic absorption more than cephalad movement of opioid

40
Q

risk factors for ventilation depression? (6)

A 
– Larger dosages
– Geriatric age
– Receiving other opioids or sedatives 
– Prolonged or extensive surgery
– Presence of co-morbidities
– Thoracic surgery
41
Q

2 things that cause an Increased risk of delayed depression

A

– Patient also receiving IV opioid or sedative

– Patient coughing to move opioid cephalad

42
Q

what pt population does vent depression affect least

A

OB bc of progesterone !!!!

43
Q

what is Most reliable sign of ventilatory depression and why?

A

decreased LOC bc pao2 late sign

44
Q

treatment of vent depression?

A

narcan 0.25 mcg/kg/hr (maybe)

45
Q

what neuraxial opioid is most r/t to sedation

A

sufent

46
Q

explain the MOA of CNS excitation from neuraxial opioid (rare)

A

cephalad migration of opioid in CSF
and interaction with non-opioid receptors in
the brainstem or basal ganglia

47
Q

what two neurotransmitters can opioids potentially block inhibition

A

GABA and glycine (meaning there is more)

48
Q

what virus is reactivated by neuraxial morphine 2-5 days after admin?

A

herpes due to trigeminal nucleus interaction

49
Q

will you see vent depression in neonate?

A

YES
Related to systemic absorption of opioid
–– Minimal opioid found in breast milk
Don’t withhold analgesics from C-section patients

50
Q

what can neuraxial opioids do to the eyeballs

A

Miosis, nystagmus, vertigo

51
Q

other side effects of neuraxial opioids?

A
  • delayed gastric emptying
  • decreased body temp
  • water retention (vaso)

Pharmacology 680 (19 decks)

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