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Surgery > Surgery Pharm > Flashcards

Surgery Pharm Flashcards

1
Q

What are the adverse outcomes of undertx perioperative pain?

A
  • thromboembolic complications
  • pulmonary complications
  • increase length of hospitalization
  • hospital readmission for further pain management
  • needless suffering
  • impairment of quality of life
  • development of chronic pain
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2
Q

Adverse outcomes of perioperative pain management?

A
  • respiratory depression
  • brain injury
  • neuro injury
  • sedation
  • circulatory depression
  • N/V
  • pruritius
  • urinary retention
  • impairment of bowel fxn
  • sleep disruption
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3
Q

What must you always document regarding pt and pain throughout operation?

A
  • pain intensity
  • effects of pain therapy
  • SEs caused by therapy
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4
Q

What are factors to consider when deciding pain management for pt?

A
  • type of surgery
  • expected severity of postop pain
  • underlying medical conditions: CVD, pulm, allergies, renal or liver failure
  • risk-benefit ratio for available techniques
  • pt’s preference
  • pt’s previous experience w/ pain
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5
Q

Preop prep of pt?

A
  • H and P

- post op pain control plan

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6
Q

What should you do preop w/ pt?

A
  • adjust or continue meds that may provoke a withrawal syndrome
  • tx to reduce preexisting pain and anxiety: consider initiaion of post op pain management
  • premeds b/f surgery
  • pt and family education:
    addiction
    adverse effects of meds
    optimal use of pt-controlled analgesia
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7
Q

Periop techniques for pain management?

A
  • central regional opioid analgesia
  • pt controlled analgesia w/ systemic opioids
  • peripheral regional analgesia:
    intercostal blocks
    plexus blocks
    local anesthetic infiltration of incisions
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8
Q

What is central regional opioid analgesia? Benefits and risks?

A
  • epidural or intrathecal admin of analgesia - epidural: injection outside of the dura
    intrathecal: aka spinal anesthesia - injection through dura directly into CSF
  • benefits: improved pain relief when preincisional epidural or intrathecal morphine is admin compared w/ po, IV, or IM morphine
  • risks: increased pruritus and urinary retention in post op epidural anesthesia compared to IM morphine
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9
Q

Amt of intrathetcal opioids admin?

A
  • intrathecal morphine (0.1-0.2 mg) or fentanyl (10-20 mcg)
  • a single dose of intrathecal opioid (morphine) can provide pain relief for up to 18-24 hrs post op: onset of action: 45 min
  • fentanyl provides pain relief for 1-2 hrs: onset of action 5-10 min
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10
Q

What is pt controlled analgesia? Benefits?

A
  • for moderate to severe post op pain
  • benefits: decreased delay in pt access to pain med, decreased likelihood of overdose
  • pump usually d/c when able to take oral meds
  • morphine, hydromorphone and fentanyl can be given via PCA
  • fentanyl is less desirable due to short DOA: may be useful if morphine allergy, easier to use in hepatic or renal insufficiency than others
  • improved pain scores comparing IV PCA morphine to intramuscular morphine
  • studies show that having IV PCA pump w/ a background infusion of morphine vs PCA pump w/o background infusion:
    more analgesic used, findings equivocal regarding pain relief, nausea, and vomiting, pruritus, sedation
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11
Q

What are multimodal techniques for pain management?

A
  • using 2 or more drugs that act by different mechanisms for providing analgesia
  • systemic meds: opioids+NSAIDs
  • central and regional meds: epidural and local anesthetics (ex: fentanyl _ bupivocaine admin via epidural): better pain control but more muscle weakness and pruritus noted
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12
Q

Benefits of systemic analgesics?

A
  • improved pain scores and reduced analgesic use when given IV morphine + ketorolac compared to IV morphine alone
  • ketorolac along w/ PCA opioid admin is more effective at decreasing pain vs COX-2 or nonselective NSAIDs
  • lower pain scores when adding gabapentin or pregabalin to IV opioids
  • unless CI pts should receive schedules regimen of NSAIDs, COXIBs or acetaminophen
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13
Q

What are peripheral regional techniques of pain management?

A
  • peripheral nerve blocks, intraarticular blocks, and infiltration of incisions
  • preop nerve blocks are effective at reducing postop pain and decrease the need for opioid use (post blocks aren’t helpful)
  • preop infiltration of the incision w/ local anesthetic (ex. Bupivicaine) decreases postop pain scores
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14
Q

What pts are at risk for inadequate pain control?

A
  • peds
  • geriatrics
  • critically ill
  • cognitively impaired
  • others who may have difficulty communicating
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15
Q

What is the role of the PA in the management of the post surgical pt?

A
  • know the pt’s hx
  • procedure performed and any complications
  • type of anesthesia used for the case
  • duration of case and if that is normal for procedure mentioned
  • what has pt received so far, did it work, any adverse rxns and what other modalities are in play? (epidural pain management, nerve block)
  • adjustment of opioid dose and/or initiation of acetaminophen, NSAIDs or gababpentin may be needed
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16
Q

Diff types of opioids?

A
  • *morphine,
  • *hydromorphone (dilaudid)
  • *fentanyl
  • meperidine
  • 3 most commonly used for post op IV pain management
17
Q

Diff routes of opioid admin?

A
  • most widely used med for tx of postop pain
  • bolus injections are often used: given this way they fail to provide steady state of drug
  • continuous infusions: may be dangerous due to potential for drug build up and cause respiratory depression, must be given in a highly supervised enviro
  • pt controlled analgesia
18
Q

Metabolism of opioids?

A
  • all opioids are hepatically metabolized to active and inactive metabolites which are eliminated in urine
  • pts w/ severe liver disease will need dosage adjustments
19
Q 
Morphine:
type, onset? 
Elimination half life?
Duration of action? 
Admin?
Excretion?
CI?
A
  • prototypical opioid
  • onset of analgesia is rapid
  • peak in 1-2 hrs
  • elim half life: 2-3 hrs
  • analgesic duration of action: 4-5 hrs
  • IV 1-3 mg q 5min until pain relief or adverse effects like sedation, hypotension, respiratory depression, and hypoxemia
  • active metabolites eliminated renally
  • in renal insufficiency active metabolites may accumulate and cause neurotoxicities: myoclonus, confusion, coma and death
  • relatively CI in severe renal disease
  • erratic absorption from GI tract
20
Q

Hydromorphone (dilaudid):

Onset, half life?

A
  • more rapid onset of analgesia reaching peak w/in 30 min
  • half life: 2.4 hrs
  • approx 4-6x more potent than morphine
  • 0.2-1 mg q 2-3 hrs
21
Q

What is fentanyl?
How powerful?
When is it preferred?

A
  • synthetic derivative of morphine
  • approx 100x more potent than morphine
    more lipid soluble than morphine:
    more rapid onset of action, improved penetration of blood brain barrier, shorter half life, eliminaton half life is 2-4 hrs
  • doesn’t release histamine and may be preferred in presence of hemodynamic instability or bronchospasm
22
Q

Fentanyl:

amt admin depending on pain?

A
  • moderate pain: 25-50 mcg IV q 5 min up to max dose
  • moderate to severe pain: 50-100 mcg q 2-5 min until pain relief
  • IV infusion for pain control in mechanically ventilated pts:
    0. 7-10 mcg/kg/hr, admin over 5 days may lead to deposition of drug in adipose tissue and prolonged sedation
23
Q

Meperidine:
Indication
CI
SEs

A
  • indicated for short term management of acute pain
  • CI in pts on MAOIs
  • lower seizure threshold
  • has dysphoric effect
  • not as effective as other drugs
  • slower rate of metabolism in elderly or if liver or renal failure
  • not usef for PCA pumps b/c of risk for accumulation of active metabolite
24
Q

SEs of opioids?

A
  • somnolence
  • depression of brainstem control of respiratory drive
  • hypotension
  • urinary retention
  • N/V
  • slowing of GI transit: constipation, ileus
  • histamine release: MC after morphine - flushing, tachycardia, hypotension, pruritus, bronchospasm
25
Q

How can you transition from IV to oral opioids?

A
  • switch from IV to oral once pt can tolerate PO
  • calculate 24 hr opioid consumption to determine coverage needed:
    consult equianalgesic charts
  • PO - analgesic effects take 30-60 min
  • switch to one of the following: oxycodone, hydrocodone, hydromorphone, morphine: ex 40 mg of IV morphine given in 24 hrs would reqr 20 mg oxycodone q 4 hrs or 5 mg of hydromorpone q 4 hrs
26
Q

What are the oral opioids used?

A

oxycodone (oxycontin) (roxicodone) -

  • oxycodone/acetaminophen (percocet)*
  • oxycodone/ibuprofen (combunox)
  • schedule II

hydrocodone (hysingla ER) (Zohydro ER):

  • hydrocodone/acetaminophen (lortab) (Vicodin) (norco)*
  • hydrocodone/ibuprofen (vicoprofen)
  • schedule III

hydromorphone (diluadid):
schedule II

morphine (Avinza) (duramorph) (kadian) (MS contin):
schedule II

  • MC used po pain meds post surgery
27
Q

Duration of action of diff opioids?

A
  • short acting: fentanyl
  • moderate acting: DOA 4-6 hrs
    morphine, codeine, hydromorphone, oxycodone
  • long acting: methadone, long acting morphine preparations
28
Q

What opioids are safe in pts w/ impaired renal fxn?

A
  • hydromorphone and oxycodone have inactive metabolites: safer than morphine for use in renal impairment
  • fentanyl: safer than morphine for use in renal impairment
29
Q

Opioid reversal agent?

A
  • naloxone (narcan)
  • reversal of respiratory depression w/ therapeutic opioid doses:
    IV, IM, Subq, endotracheally:
    initial 0.04-0.4 mg:
    may repeat until desired response achieved. If desired response isn’t observed after 0.8 mg total, consider other causes of respiratory depression
30
Q

What are non-opioid adjunctive meds used?

A
  • NSAIDs
  • ketamine
  • lidocaine
  • magnesium
  • IV acetaminophen
31
Q

Use of NSAIDs?

A
  • can reduce dose of opioid reqd
  • caution w/ kidney impairment
    nonselective:
    -IV formulations: ketorolac and ibuprofen
    -ketorolac reduces opioid constipation by 25-45%
    -ketorolac dose 15-30 mg IV over 15 sec
  • then dose q 6 hrs x 3-5 days

selective:
no IV formulation available, sometimes just a single dose might suffice

32
Q

Dosing of oral NSAIDs?-

A
  • nonselective PO or PR:
    ibuprofen 400mg q 4-6 hrs
    diclofenac 50 mg q8hrs
    ketoprofen 50 mg qid

-selective:
celecoxib (celebrex): 400 mg po x 1 then 12 hrs later start 200 mg po BID

33
Q

What is ketamine? Use?

A
  • NMDA receptor inhibitor
  • use limited due to hallucinations
  • reduces hyperalgesia and opioid tolerance
34
Q

Use of acetaminophen? CI?

A
  • oral or rectal 1st line then can give IV: 325 mg-1000 mg PO or PR q 4-6 hrs/max dose 4 g
  • may be given in addition to NSAIDs
  • CI in hepatic failure
35
Q

use of lidocaine?

A
  • class I antiarrhythmic
  • IV infusion intra-op or post-op for control of pain
  • 1.5-2 mg/kg bolus then 1.5-3mg/kg/hr
  • most effective for analgesia following major abdominal surgery
36
Q

Use of Mg sulfate?

A
  • can reduce opioid requirements
  • NMDA receptor antagonist
  • bolus or infusion
  • not routinely used at this time despite many studies to show its effectiveness

Surgery (19 decks)

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