Pharmacology Flashcards
Goal of Peri-Operative Pain Management
Have the patient comfortable when they awaken from anesthesia
SE of Peri-Operative Pain
Thromboembolic complications Pulmonary complications Increased length of hospitalization Hospital readmission for further pain management Needless suffering Impairment of QOL Development of chronic pain Respiratory depression Brain injury Neurologic injury Sedation Circulatory depression N/V Pruritis Urinary retention Impairment of bowel function
What must we always document?
Pain intensity
Effects of pain therapy
SE caused by therapy
Factors to Consider When Approaching a Patient with Pain
Type of surgery Expected severity of postoperative pain Underlying medical conditions Risk:benefit ratio for the available techniques Patient's preferences Patient's previous experience with pain
How to Prepare the Patient Medication Wise for Surgery
Adjust/continue meds that may provoke withdrawal symptoms
Reduce anxiety & pain
Patient & family education
Patient & Family Education Prior to Surgery
Addiction
Adverse effects of meds
Optimal use of PCA pump
Perioperative Techniques for Pain Management
Central regional opioids analgesia
Patient controlled analgesia with systemic opioids
Peripheral regional analgesia
Epidural Administration of analgesia
Injection outside of the dura
Can be placed anywhere along the spine
Intrathecal/spinal Administration of Anesthesia
Injection through the dura directly into the SAF
Benefits of Central Regional Opioid Analgesia
Improved pain relief when preincisional morphine is administered
Risks of Central Regional Opioid Analgesia
Increased pruritus
Increase urinary retention post up
How long can a single dose of intrathecal morphine provide pain relief for?
18-24 hours
When is a PCA indicated?
Moderate to severe post op pain
Benefits of PCA Pumps
Decreased delay in patient access to pain medication
Decreased likelihood of overdose
When is a PCA pump discontinued?
When the patient can take oral medications
What medications can be given via a PCA pump?
Fentanyl
Hydromorphone
Morphine
Multiple Techniques for Pain Management
2+ drugs by different mechanisms
Opioid + NSAIDs
Central + regional meds
Peripheral Regional Techniques
Peripheral nerve blocks
Intra-articular blocks
Infiltration of incisions
When should a nerve block be performed?
Pre-operative
Patients at Risk for Inadequate Pain Control
Pediatrics Geriatrics Critically ill Cognitively impaired Others with difficulty communicating
3 Most Common IV Analgesics
Morphine
Hydromorphone (Dilaudid)
Fentanyl
How must opioids be given when postoperative?
IV
In a highly supervised environment
Where are all opioids metabolized?
Through the liver
Morphine
Rapid onset
Peak: 1-2 hours
Duration: 4-5 hours
IV 1-3 mg Q 5 minutes
SE of Morphine
Sedation
Respiratory depression
Hypoxemia
Renal Insufficiency & Morphine
Active metabolites may accumulate
Neurotoxicities: myoclonus, confusion, coma, death
Relative Contraindication of Morphine
Severe renal disease
Hydromorphone (Dilaudid)
Onset: 30 minutes
4-6 times more potent than morphine
0.2-1 mg q 2-3 hours
Fentanyl
100 times more potent than morphine More lipid soluble than morphine Rapid onset Improved penetration of blood-brain barrier Shorter duration of action
When is fentanyl used?
Moderate pain
Moderate to severe pain
Pain control in ventilated patients
When is meperidine (demorol) indicated?
Short term management of acute pain
Contraindications of Meperidine (Demarol)
MAOIs
SE of Meperidine (Demorol)
Lowers seizure threshold
Dysphoric effect
General Opioid SE
Somnolence Depression of respiratory drive Hypotension Urinary retention N/V Slowing of GI transit Histamine release
Signs of Histamine Release from Opioids
Flushing Tachycardia Hypotension Pruritus Bronchospasm
Oral Opioids for Post-Operation
Oxycodone
Hydrocodone
Hydropmorphone
Morphine
Most Common Oxycodone Medication
Oxycodone/acetaminophen (Percocet)
Most Common Hydrocodone Medication
Hydrocodone/acetaminophen (Lortab or Vicodin or Norco)
Short Acting Opioids
Fentanyl
Moderate Action Opioids
Morphine
Codeine
Hydropmorphone
Oxycodone
Medications that are Safer in Renal Impairment
Hydromorphone
Oxycodone
Fentanyl
Opioid Reversal Agent
Naloxone (Narcan)
MOA of Naloxone (Narcan)
Reversal of respiratory depression
Non-Opioid Adjunctive Medications
NSAIDs Ketamine Lidocaine Magnesium IV acetaminophen
Why is ketamine use limited?
Hallucinations
What does ketamine reduce?
Hyperalgesia
Opioid tolerance
Contraindication of Acetaminophen
Hepatic failure
When is lidocaine most effective?
After major abdominal surgery
