Week 11: Acute Pain Flashcards

Question

Ketorolac in peds

Answer 1

* NSAID * Available PO, IV, IM * Potential opioid sparing effect * Cannot be used for a long time * No more than 24-72 hours in children less than 2 years * No more than 5 days in children 2 and older

Answer 2

* PO: 0.2-0.5 mg/kg every 4-6 hours * IV: 0.05-0.2 mg/kg every 2-4 hours * PCA: 0.015 mg/kg/hr basal with 0.015 mg/kg PCA dose q10 min lockout

Answer 3

_Oxycodone_ * 4-5 hour duration _Fentanyl_ * Potent (100x morphine), short duration * Transdermal patch has long onset and long acting (2-3 days) _Hydromorphone_ * 5x more potent than morphine * 4-6 hour duration

Answer 4

\*Primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. \*Characterized by behaviors that include one or more of the following: * impaired control over drug use * compulsive use * continued use despite harm * craving

Answer 5

* Casual use sensitizes reward system * high motivation to repeat rewarding behaviour for pleasurable experience

Answer 6

* Chronic exposure and production of stress factors and negative emotional state, withdrawal and anxiety * Use to avoid negative-affect state

Answer 7

* Reward system responds – corticotropic releasing factors and stress factors reduced

Answer 8

Dopamine reward threshold increases, pleasure decreases

Answer 9

Modulation of withdrawal, stress and anxiety

Answer 10

State of adaptation that is manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist ## Footnote

Answer 11

* The body's physical adaptation to a drug: * Greater amounts of the drug are required over time to achieve the initial effect as the body adapts to the intake

Answer 12

* Term used to describe patient behaviors that may occur when pain is undertreated * May become focused on obtaining medications, "clock watch," seem inappropriately "drug seeking." * Illicit drug use and deception can occur in the patient's efforts to obtain relief * Distinguished from true addiction in that the behaviors resolve when pain is effectively treated.

Answer 13

* Work at site of tissue injury to prevent the formation of the nociceptive mediators Prostaglandins * Can decrease opioid use ~30% therefore decreasing opioid-related side effects * Minor surgeries can use NSAIDs instead of opioids to completely eliminate opioid-associated side effects * Side effects: GI upset, gastric ulcers, decrease renal medullary blood flow, reversible inhibition of platelet function * Newer NSAIDS selectively (primarily) inhibit cyclooxygenase-2 (COX-2) which is induced by surgical trauma with minimal effect on COX-1 which is responsible for GI and platelet side effects * Celecoxib (Celebrex)

Answer 14

_Patient factors_: Low pain tolerance, opioid tolerance, Sleep apnea, Narcolepsy, Obesity, COPD, Cardiac disease, Elderly – those at risk for post-operative cognitive dysfunction _Epidural Infusion_: * Used for major surgery ie. oncologic TAH BSO, thoracotomy * Ideally placed pre-operatively and used in combination with a GA for surgery and continued ~ 2 days * Usually patient is tolerating diet and ambulation to chair when epidural is D/C

Answer 15

* When placed at the level of the incision and with a constant infusion of LA and opioid: * Minimal or no pain at all, particularly with movement * No motor block: Can ambulate * Speedier return of bowel function: With more LA and less opioid –Cochrane review 2003 * Less nausea * Less sedation * Less delerium * Do not require supplemental IV opioids and associated side effects * Less pulmonary complications: Quicker extubation, better oxygen saturation, less pneumonia

Answer 16

Hypotension * LA causes a sympathectomy which leads to vasodilatation * Mild volume depletion, which can normally be compensated for with vasoconstriction, will be unmasked with an epidural * Pts require adequate volume status with an epidural * Pts will initially c/o dizzyness, lightheadedness and nausea when sitting up or standing * Can document orthostatic hypotension * Will then progress to supine hypotension if not corrected * Major problem POD #1 when 3rd spacing still occurring, minimal IV fluids infusing and pt NPO _Leg weakness or numbness_ * Can occur if catheter is too low (low thoracic or lumbar) or if it is one-sided * Inhibits ambulation and distressing to pt therefore must be fixed * Infusion can be adjusted or catheter pulled back * \*Must be addressed as this is the first sign of epidural hematoma leading to permanent paralysis\* _Post dural puncture headache 1:100_ * Only if dura is unintentionally punctured * More likely in younger people I**_nfection_** * Some reports of epidural abscess as high as 1:1900 * Usually just superficial skin infections * Increased risk in immunosuppressed _Epidural hematoma_ * Most feared complication * Incidence of 1:180 000 – 1:220 000: Increased with heparin, age, gender, ASA, NSAIDs, traumatic placement, spinal stenosis * Leg weakness, numbness and bladder/bowel disturbance are first signs * If not evacuated within 8-12 hours, usually leads to permanent paralysis

Answer 17

* Abnormal coagulation * Elderly * Female * Debilitated patients * Traumatic insertion * Unknown spinal pathology

Answer 18

* ASA – OK * NSAIDS – OK * UFH 5000 sc bid – OK if no other antiplatelets * UFH 5000 sc tid – sort of OK, but not really (according to ASRA) * LMWH (Dalteparin)– increased risk – not really OK * IV heparin – not OK * Clopidigrel, ticlodipine – not OK * Coumadin – not OK

Answer 19

* Massage therapy:This may help relax tight muscles and decrease pain. * Physical therapy: This teaches you exercises to help improve movement and strength, and to decrease pain. * Aromatherapy: This is a way of using scents to relax, relieve stress, and decrease pain. Aromatherapy uses oils, extracts, or fragrances from flowers, herbs, and trees. They may be inhaled or used during massages, facials, body wraps, and baths. * Laughter: Laughter may help you let go of stress, anger, fear, depression, and hopelessness. * Music: This may help increase energy levels and improve your mood. It may help reduce pain by triggering your body to release endorphins. These are natural body chemicals that decrease pain.