post op pain Flashcards
what can make acute pain worse
anxiety
increased sympathetic output
poor rest
inadequate oral intake
opioids and non opioids modulate pain..
peripherally and centrally
serious side effects of NSAIDS
GI toxicity
decreased renal function
absolute contraindications to NSAIDs
allergy
pregnancy
erosive or ulcerative conditions of the GI mucosa
relative contraindications to NSAIDs
asthma
anticoagulant therapy or hemorrhagic disorders
compromised renal function
COX-2 selective NSAIDs action
anti inflammatory, anty pyretic, analgesic
protect normal physiologic processes
why dont we just use COX-2 inhibitors only
poor efficacy in third molars
expensive
only one option
increased embolic phenomena
SULFA ALLERGY
how does acetaminophen work
probably blocks PG synthesis in CNS
does acetaminophen have anti inflammatory effects n
no
recommended daily maximum for tylenol
FDA: 4000 mg/day
McNeil Consumer: 3000 mg/day
daily maximum of tylenol for ppl with liver disease
2000 mg/day
which opioid receptors are more potent as far as analgesia, resp depression, sedation
mu > kappa
rank from most potent to least: hydro, oxygen, codeine
oxy > hydro > codeine
how do tylenol and semi synthetic opiate receptors work together
synergistically
reduces Amt of opioid needed, tylenol dictates dose/frequence
what converts oral opiates to active metabolites
cyp450
codeine active metabolite
morphine (effect entirely from metabolite)
hydrocodone active metabolite
hydromorphone (effect from parent drug and metabolite)
oxycodone active metabolite
oxymorphone (effect almost entirely from parent drug)
how many caucasians are deficient in cyp450
4-10%
pentazocine MOA
oral agonist-antagonist
analgesic at kappa, antagonist at mu
is pentazocine good for third molars
no
tramadol MOA
central dual action:
weak binding at mu
inhibit incoming nociceptive impulses
what type of pain is tramadol good for
chronic
is tramadol better than opioid-tylenol combos
no
how long/what severity is pain for dentoalveolar surgery usally
mild to moderate
3-5 days
pre surgical eval for pain
type of surgery, expected pain
pre existing medical condiitons/medications
patients previous experience
why is giving po analgesics prior to surgery a good idea
inhibits PG synthesis
lessens nocicpetion during procedure will reduce overall post op analgesic requirement
what local anesthetic should you give prior to sx
bupivicaine
blocks input to CNS, decreases central hyper excitability, less pain and analgesic intake and 4h and 8 h, easier to maintain pain free state
which analgesics better for dental pain
NSAIDs better than opioids (inflammatory)
what is NSAID of choice
ibuprofen, nothing is proven to be better or cheaper
t/f: NSAIDs have ceiling effect for analgesic properties
true
how to chose dose of NSAID
according to contribution of inflammation to the pain experienced
dose frequency for non narcotic analgesics
around the clock on fixed schedule regardless of pain severity
prn = haphazard drug levels
ibuprofen dose and max dose
600 mg q6h
3200 mg
tylenol dosage, max dose
650 mg q6h (healthy); 3000 max
500 mg q6h (liver pt); 2000 max
breakthrough pain management
small doses of short acting opioid agents if non-opioid regimen is already optimized
codeine + acetaminophen brand name, dose
tylenol #2 = 15
tylenol #3 = 30
tylenol #4 = 6-
hydrocodone + acetaminophen brand name, dose
norco 5/325
oxycodone + acetaminophen brand name, dose
percocet 5/325
stepped approach
step one: ibuprofen 600 mg q6h, tylenol 650 mg q6h
step two: norco or percocet prn
Dr. Kennedy’s plan for routine third molars
pre emptive: ibuprofen 600 mg po, ketorolac 30 mg IV
local: 2% lido, 0.5% bupivicaine
post op: ibuprofen/tylenol q6h for 72 hours, norco one tab prn for severe pain
dosing may not exceed ____g morphine equivalent doses
30 mg
opioid rx requirements
CDT code and days worth
which trimester is best for tx preggo
second
what local to use for preggo
lido
analgesics for preggo
no NSAIDS
tylenol, narcotic w/ OB approval ok
chronic opioid users pain management
post op pain is in addition to pain they already have
discuss pre op with pt and doctor
optimize daily non-opoiod routine
tolerance may require increase in opioid dosage
rehab ppl pain management
discuss up front
use LA, NSAIDs
dont rx something they have abused in the past
drug rxn that is not anaphylaxis tx
DC drug
antihistamines
corticosteroids
are allergic reactions common with opoids
no but adverse effects are
how to avoid adverse effects of opioids
dose reduction
opioid rotation
manage adverse effects
corticosteroids uses in dentistry
topical
enteral (po) for trismus/edema
tx of non anaphylactic drug allergy
contraindications to corticosteroid use
history of chronic infection
peptic ulcer dz
DM
poor wound healers
caution w/ simultaneous NSAID use
how many adrenal crisises have there been in last 66 yeras
6
when to consider stress dose of steroid
20 mg prednisone per day for more than two weeks in the past two months
