PPT - PAIN, NAUSEA, VOMITING, IV FLUIDS

Question 1

What are examples of strong opioids?

Answer 1

Morphine
Diamorphine
Buprenorphine
Dipipanone hydrochloride
Afentanil
Fentanyl
Remifentanil
Methadone
Oxycodone
Pentazocine
Pethidine
Tapentadol
Tramadol

Question 2

What are examples of weak opioids?

Answer 2

Codeine phosphate
Dihydrocodeine tartrate
Meptazinol

Question 3

What are the acute side effects of opioids?

Answer 3

Nausea
Sedation
Confusion
Hallucinations
Flushing and sweating
Dry mouth
Hypotension
Pruritis and urticaria (‘morphine itch’ caused by mast cell degranulation)
Delirium
Myoclonus
Hyperalgesia
Visual disturbance
Respiratory depression

Question 4

What are the chronic side effects of opioids?

Answer 4

Constipation
Difficulty with micturition and urinary retention
Delirium
Sexual dysfunction
Biliary/ureteric spasm

Question 5

How do you manage respiratory depression from opioid use?

Answer 5

Naloxone

Question 6

What are the key things to remember about naloxone?

Answer 6

Half life is much shorter than other opioids
Rapid onset - it can restore normal breathing in 2-3 minutes

Question 7

What ate the features of opioid misuse?

Answer 7

rhinorrhoea
needle track marks
pinpoint pupils
drowsiness
watering eyes
yawning

Question 8

What is pethidine?

Answer 8

A synthetic opioid which is structurally different from morphine but which has similar actions. Has 10% potency of morphine.
Short half life and similar bioavailability and clearance to morphine.
Short duration of action and may need to be given hourly.

Question 9

Why do anaesthetists use multi-modal analgesia? (I.e. using more than 1 drug)

Answer 9

To target different parts of the pain pathway
Allows you to use a lower dose if any - particularly important in opioids

Question 10

What are the main effcts of morphine?

Answer 10

Pain relief
A state of euphoria and mental detachment
Commonly causes nause and vomiting

Question 11

What is Buprenorphine?

Answer 11

Has both opioid agonist and antagonist proerpties and may precipitate withdrawal symptoms in pt dependant on other opioids

Question 12

What receptors do we want to target our drugs at for travel sickness?

Answer 12

H1 and M1 in vestibular system

Question 13

What receptors do we want to target our drugs at for nausea caused by drugs such as opioids?

Answer 13

Target CTZ or vomiitng centre - D2, neurokinine and 5-HT3 receptor

Question 14

What receptors do we want to target our drugs at for nausea caused by something in the GIT?

Answer 14

Mechanoreceptors
Chemoreceptors
5HT3 receptors

Question 15

What drugs do we give for post-operative nausea?

Answer 15

Serotonin receptor antagonists e.g. ondansetron

Others:
Glucocorticoids - dexamethasone
Anticholinergic e.g. promethazine
Neurokinin receptor antagonist e.g. aprepitant

Question 16

Whats the current issue with using cylizine for nausea?

Answer 16

IV cyclizine has actually been shown to give a ‘rush’ so there is abuse potential - recently people have been faking nausea and vomiting in ED in order to receive IV cyclizine

Question 17

Why did we move away from using IV pethidine for renal colic?

Answer 17

The abuse potential - pt would come in to ED Pethidine seeking
We now use IM diclofenac

Question 18

Whats the moa of Ondansetron?

Answer 18

5HT3 antagonism both peripherally and in CTZ

Question 19

Whats the issue with Ondansetron at a high dose?

Answer 19

Can prolong the QT interval

Question 20

Whats the moa of glucocorticoids for post operative nausea and vomiting?

Answer 20

Not known

Question 21

Whats the moa of anticholinergic drugs for post operative nausea and vomiting?

Answer 21

Unknown - possibly by blocking communication to vomitin centre

Question 22

Whats the moa of neurokinin-receptor antagonists for post operative nausea and vomiting?

Answer 22

Blocks neurokinin effect at receptor site (this is a proemetic agent)

Question 23

Whats the issue with neurokinin receptor antagonists?

Answer 23

Expensive!!

Question 24

Whats the problem with metoclopramide use for emesis?

Answer 24

It causes acute dystonia - particularly in young females

Question 25

What can you give to treat drug-induced dystonia reactions?

Answer 25

Procyclidine

Question 26

Who should not receive metoclopramide?

Answer 26

Anyone under 20 particularly females

Question 27

What are examples of sodium containing fluids?

Answer 27

0.9% sodium chloride (isotonic)
Hartmanns solution - compound sodium lactate (isotonic)

Question 28

What are examples of glucose containing fluids?

Answer 28

5% glucose (isotonic)
10% glucose, 20% glucose or 50% glucose (hypertonic examples)

Question 29

Outline the NICE guidelines for fluid resuscitation?

Answer 29

Give a fluid bolus of 500m crystalloid fluids over <15 minutes (e.g. 0.9% sodium chloride or Hartmanns)
Reassess using ABCDE
If they still need fluid then give further fluid bolus of 250-500ml of crystalloid
Up until the point you reach 2L of fluid - after this point you need to seek expert help

Question 30

Outline NICE guidance for routine fluid maintenance?

Answer 30

Maintenance IV fluids:
25-30ml/kg/d of water
1mmol/kg/day sodium, potassium + chloride
50-100g/day glucose

Reassess and monitor the pt

Question 31

How logbook does oramorph last?

Answer 31

4 hours
give 6 times a day or every 4 hours

Question 32

Whats the risk of using large volumes of 0.9% saline?

Answer 32

Increased risk of hyperchloraemic metabolic acidosis

Question 33

When is hartmanns contraindicated?

Answer 33

In hyperkalaemia as it contains K+