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SURGERY EXAM II > SURGERY PHARMACOLOGY > Flashcards

SURGERY PHARMACOLOGY Flashcards

1
Q

GOAL OF PERIOPERATIVE PAIN MANAGEMENT =

A

to have the patient comfortable when they awaken from anesthesia

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2
Q

ADVERSE OUTCOMES OF UNDERTREATED PERIOPERATIVE PAIN

A 
⦁	Thromboembolic complications
⦁	Pulmonary complications
⦁	Increased length of hospitalization
⦁	Hospital readmission for further pain management
⦁	Needless suffering
⦁	Impairment of quality of life
⦁	Development of chronic pain
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3
Q

ADVERSE OUTCOMES OF PERIOPERATIVE PAIN MANAGEMENT

A 
Respiratory depression
Brain injury
Neurologic injury
Sedation
Circulatory depression
Nausea and vomiting
Pruritus
Urinary retention
Impairment of bowel function
Sleep disruption
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4
Q

must always document

A

⦁ pain intensity
⦁ the effects of pain therapy
⦁ the SE caused by pain therapy

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5
Q

approach to the patient: factors to consider

A

⦁ Type of surgery
⦁ Expected severity of postoperative pain
⦁ Underlying medical conditions
⦁ CVD, Pulmonary, allergies, renal or liver failure
⦁ Risk-benefit ratio for the available techniques
⦁ Patient’s preferences
⦁ Patient’s previous experience with pain

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6
Q

pre-op prep of patient

A
  • History
  • PE
  • Post-op pain control plan
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7
Q

perioperative techniques for pain management

A
  • central regional opioid analgesia
  • patient controlled analgesia with systemic opioids (PCA)
  • peripheral regional analgesia (intercostal blocks, plexus blocks, local anesthetic infiltration of incisions)
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8
Q

CENTRAL REGIONAL OPIOID ANALGESIA

A
  • epidural or intrathecal administration of analgesia
    ⦁ epidural = injection outside the dura
    ⦁ intrathecal (spinal) = injection through the dura, directly into the CSF

Benefits = improved pain relief when preincisional epidural or intrathecal morphine is given compared with 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

intrathecal administration of opioids

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 hours post-op
    ⦁ onset of action = 45 minutes
  • Fentanyl provides pain relief for 1-2 hours
    ⦁ onset of action = 5-10 minutes
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10
Q

PATIENT CONTROLLED ANALGESIA

A
  • for moderate to severe post-op pain

Benefits = decreased delay in patient access to pain medication, and decreased likelihood of overdose

  • the pump is usually discontinued when able to take oral meds
  • morphine, hydromorphone and fentanyl can be given PCA
  • Fentanyl = less desirable due to short DOA (may be useful with morphine allergy, and is easier to use in hepatic or renal insufficiency than others)
  • Improved pain scores with IV PCA (patient controlled analgesia) when compared to IM morphine
  • studies show that having an IV PCA pump with a background infusion of morphine vs PCA pump without background infusion
    ⦁ more analgesic used
    ⦁ equal amounts of pain relief, nausea, vomiting, pruritus, and sedation
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11
Q

why is fentanyl less desirable for analgesia

A

shorter duration of action

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12
Q

when is fentanyl used

A

morphine allergy

easier to use in hepatic or renal insufficiency

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13
Q

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 + local anesthetics (fentanyl + bupivocaine)
  • have better pain control with multi-modal, but more muscle weakness & pruritus
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14
Q

systemic analgesics

A
  • improved pain scores & reduced analgesic use when given IV morphine + ketorolac compared to IV morphine alone
  • Ketorolac (NSAID) along with PCA opioid administration = more effective at decreasing pain vs COX 2 or nonselective NSAID
  • Lower pain scores when adding gabapentin or pregabalin to IV opioids

Unless contraindicated, patients should receive scheduled regimens of NSAIDS, COXIBs or acetaminophen

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15
Q

PERIPHERAL REGIONAL TECHNIQUES

A
  • peripheral nerve blocks, intra-articular blocks, and infiltration of the incisions
  • preoperative nerve blocks are effective at reducing post-op pain and decreasing the need for opioid use (post-op blocks are not as helpful)
  • Pre-op infiltration of the incision with local anesthetic (ex: Bupivicaine) decreases post-op pain scores
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16
Q

patients at risk for inadequate pain control

A 
⦁	Pediatrics
⦁	Geriatrics
⦁	Critically ill
⦁	Cognitively impaired
⦁	Others who may have difficulty communicating
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17
Q

OPIOID DRUGS

A 
OPIOIDS
⦁	Morphine
⦁	Hydrophormone (Dilaudid)
⦁	Fentanyl
⦁	Meperidine

3 most commonly used for post-op IV pain management = Morphine, Dilaudid & Fentanyl

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18
Q

most widely used meds for tx of post-op pain

A

opioids

19
Q

OPIOIDS

A
  • Most widely used medication for the treatment of postoperative pain
  • Bolus injections are often used
    ⦁ Given this way = they fail to provide a steady state of the drug

Continuous infusions
⦁ May be dangerous due to the potential for drug build up and cause respiratory depression
⦁ Must be given in a highly supervised environment

  • Patient controlled analgesia
20
Q

opioid metabolism

A
  • all opioids are hepatically metabolized to active and inactive metabolites, which are eliminated in the urine
  • patients with severe liver disease will need dosage adjustments
21
Q

MORPHINE

A
  • rapid onset
  • duration = 4-5 hours
  • need to dose adjust for kidneys; pts with renal dysfunction = at risk for toxicity
  • active metabolites are eliminated renally; so in renal insufficiency, active metabolites may accumulate and cause neurotoxicities (myoclonus, confusion, coma, death)
  • relatively contraindicated in severe renal disease
  • erratic absorption from the GI tract
22
Q

HYDROMORPHONE (DILAUDID)

A
  • more rapid onset of analgesia than morphine

- about 4-6x more potent than morphine

23
Q

FENTANYL

A
  • synthetic derivative of morphine
  • about 100x more potent than morphine
  • more lipid soluble than morphine; so more rapid onset of action, improved penetration of BBB, shorter half-life, and elimination half life = 2-4 hours
  • does NOT release histamine - and may be preferred in the presence of hemodynamic instability or bronchospasm

⦁ administration > 5 days may lead to deposition of drug in adipose tissue and prolonged sedation

24
Q

contraindicated in patients with MAOIs

A

meperidine

25
Q
  • indicated for short term management of acute pain
    lowered seizure threshold
    has dysphoric effect
A

meperidine

26
Q

MEPERIDINE

A
  • indicated for short term management of acute pain
  • contraindicated in patients on MAOIs
  • lowers seizure threshold
  • has a dysphoric effect
  • not as effective as other drugs
  • slower rate of metabolism in elderly or if liver / renal failure
  • not used for PCA pumps because of the risk for accumulation of the active metabolite

not used often because of lowered seizure threshold & dysphoric effect

27
Q

histamine release = most common with which opioid

A

morphine

28
Q

OPIOID SE

A

Somnolence
Depression of brainstem control of respiratory drive
Hypotension
Urinary retention
N/V
Slowing of GI transit
Constipation, ileus
Histamine release (most common after morphine)
Flushing, tachycardia, hypotension, pruritus, bronchospasm

29
Q

transitioning from IV to oral opioids

A
  • Switch from IV to oral once the patient can tolerate PO
  • Calculate the 24 hour opioid consumption to determine the coverage needed
    ⦁ Consult equianalgesic charts
  • PO – analgesic effects take 30-60 minutes
  • Switch to one of the following: Oxycodone, hydrocodone, hydromorphone, morphine
    ⦁ Ex: 40 mg of IV morphine given in 24 hours would require 20 mg oxycodone Q 4 hours or 5 mg of hydromorphone Q 4 hours
30
Q

ORAL OPIOIDS

A

⦁ Oxycodone (Oxycontin) (Roxicodone) = Schedule II

- Oxycodone + Acetaminophen = Percocet
- Oxycodone + Ibuprofen = Combunox

⦁ Hydrocodone = Schedule III
Hydrocodone + Acetaminophen = Lortab, Vicodin, Norco
Hydrocodone + Ibuprofen = Vicoprofen

⦁ Hydromorphone (Dilaudid) = Schedule II
⦁ Morphine = schedule II

31
Q

opioid duration of action

A

Fentanyl = short acting

Morphine / Codeine/ Hydromorphone / Oxycodone = intermediate acting

Methadone = Long acting

32
Q

patients with renal dysfunction

A

⦁ Hydromorphone & Oxycodone = have inactive metabolites = are safer than morphine for use in renal impairment

⦁ Fentanyl = also safer than morphine for use in renal impairment

33
Q

OPIOID REVERSAL

A
  • Naloxone (Narcan)
  • reversal of respiratory depression with therapeutic opioid doses
  • given IV, IM, SQ, or endotracheal
  • initially = give 0.04 - 0.4 mg; may repeat until desired response is achieved; if not observed after 0.8 mg total, consider other causes of respiratory depression
34
Q

NON-OPIOID ADJUNCTIVE MEDICATIONS

A 
⦁	NSAIDS
⦁	Ketamine
⦁	Lidocaine
⦁	Magnesium
⦁	IV Acetaminophen
35
Q

don’t give ketorolac to

A

elderly patients & renal dysfunction

36
Q

NSAIDS

A
  • administration of NSAIDS can reduce the does of opioid required
  • caution with kidney impairment (and elderly)
  • Non-selective NSAIDS (inhibits COX1 & COX2)
    ⦁ IV formulations : Ketorolac & Ibuprofen
    ⦁ Ketorolac reduces opioid consumption by 25-45%
  • Selective NSAIDS
    ⦁ no IV formulations available
    ⦁ sometimes just a single dose will suffice
37
Q

acetaminophen = contraindicated in

A

hepatic failure

38
Q

first line acetaminophen route

A

oral or rectal first line

then IV

39
Q

ORAL NSAIDS

A
  • Non-selective PO or PR
    ⦁ Ibuprofen
    ⦁ Diclofenac
    ⦁ Ketoprofen
  • Selective
    ⦁ Celecoxib (Celebrex)
40
Q

KETAMINE

A
  • NMDA receptor inhibitor
  • use is limited due to hallucinations
  • reduces hyperalgesia & opioid tolerance
41
Q

ACETAMINOPHEN

A
  • oral or rectal = first line
  • then try IV
  • may be given in addition to NSAIDS
  • Contraindicated in hepatic failure
42
Q

LIDOCAINE

A
  • class I antiarrhythmic
  • IV infustion intra op or post-op for pain control
  • most effective for analgesia following major abdominal surgery
43
Q

MAGNESIUM SULFATE

A
  • can reduce opioid requirements
  • NMDA receptor antagonist (just like ketamine)
  • Bolus or Infusion
  • Not routinely used at this time, despite many studies that show its effectiveness

SURGERY EXAM II (7 decks)

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