Flashcards in Acute Pain Deck (72):
What is ketorolac?
Very potent NSAID
What is the onset of analgesia for ketorolac?
What is the peak effect of ketorolac?
What is the duration of ketorolac?
When is ketorolac contraindicated?
Labor and delivery
What do all NSAIDs increased the risk of in post-op CABG surgery?
MI and Stroke
What are the 3 IV opioids?
Which IV opioid accumulates in renal impairment?
How does morphine cause hypotension?
What is a good IV alternative for morphine-intolerant pts?
What do all IV opioids cause?
What is similar to fentanyl in potency and PK parameters?
What kind of metabolism does remifentanil show?
When is meperidine used?
Labor and delivery
Reduce rigors associated w/amphotericin toxicity
What may be found PRN on a chart if the patient is receiving IV opioids?
Why does naloxone require repeated doses?
Short 1/2 life elimination compared to opioids
What is the onset of IV naloxone?
Who should not receive PCA?
H/o substance abuse
Anticipated short duration of opioid use
Who has an indication for PCA?
Sickle cell crisis
What are the goals of PCA therapy?
Pain score 4 or less
Avg 2-3 PCA doses/hr
Maintain O2 sat and RR
Wean off PCA, decrease basal rate
What is the first step in adjusting PCA in opioid-naive patients?
Increase dose first
What do we do if increasing the dose of PCA is not enough for the pain?
Consider adding basal rate (if not prescribed already)
Start at low end of dosing range or 1/3 of average hourly usage for at least the past 12 hours
How do we adjust PCA doses in opioid tolerant patients?
Increase basal rate up to 2/3 of average hourly usage
How do we start PCA in a opioid tolerant patient?
Will likely need basal rate and higher PCA dose
What are ways to administer spinal opioids?
When is neuraxial analgesia indicated?
Labor and delivery
Where is an epidural administered?
Outside the dura mater
Space b/n the dura mater and ligamentum flavum
Contains fat, lymphatics, arterioles, and veins w/nerve roots
How does the drug that is administered via an epidural make it into the CSF?
Drug diffuses through the dura into the CSF
Where is an intrathecal opioid administered?
In the space under the arachnoid membrane
Intrathecal space = subarachnoid space
-B/n the arachnoid mater and pia mater
How does the drug that is administered via an intrathecal injection make it into the CSF?
Drug is delivered directly into the CSF and superficial spinal cord
What are the approximate equivalencies of morphine from an IV to epidural to intrathecal dose?
10mg IV = 1mg epidural = 0.1mg intrathecal
Which opioids used in neuraxial analgesia are highly lipid soluble?
Which opioids used in neuraxial analgesia have lower lipid solubility?
Which neuraxial analgesics have a rapid onset of analgesia?
Which neuraxial analgesics have a delayed/slower onset of analgesia?
Which neuraxial analgesics are more rapidly cleared from the CNS?
Which neuraxial analgesics have a prolonged half life in the CNS?
What is a serious AE of neuraxial analgesics?
What increases the risk of a hematoma formation?
When is the risk of a hematoma forming greatest?
During placement/removal of catheter
When is neuraxial analgesia contraindicated?
Infection of the lower back
Increased intracranial pressure
What type of solution must intrathecal and epidural agents be?
When is the risk of long term treatment increased in opioid-naive, non-cancer pts?
With each additional day of medication use after 3 days
After a second prescription/refill
700+ mg morphine equivalent cumulative dose
Exceeded 10 or 30 day supply
Initiated on a long-acting opioid
Initiated on tramadol
What is the definition of tolerance?
The reduction of drug effect over time as a result of exposure to the drug
What is the definition of dependence?
When an abstinence syndrome occurs following administration of an antagonist drug or abrupt dose reduction or d/c of an opioid
What is the definition of addiction?
Ongoing substance use despite known harmful consequences to health or relationships
What is the definition of pseudoaddiction?
Person exhibits behaviors suggestive of addiction but in reality are a reflection of unrelieved pain
How long until a patient has physical and psychological opioid dependence?
Approximately 3 weeks of daily opioid use
What are the sx of WD after 3-4 hours of non-use?
Fear of WD
What are the sx of WD after 8-14 hours of non-use?
What are the sx of WD after 1-3 days of non-use?
What opioids can be given to treat acute WD?
What is the new term for detoxification?
Medically supervised WD
What drugs should be used for detox?
What medications can be used for sx relief in detox?
What is the length of time for drugs of abuse that can be detected in the urine?
About 48 hours
How do we evaluate a urine sample?
Appearance and color
Concentration of urine
Urine pH, specific gravity, CrCl
What are the two types of urine tests?
Gas chromatography-mass spectrometry (GC-MS)
What is the most common initial urine test?
How does immunassay work?
Uses antibodies to detect the presence of parent drug or metabolites
What is a negative about immunoassays?
False positives can occur d/t other substances
If a patient's immunoassay tests positive, does that mean that they took something?
No, it is presumptive
When is the GC-MS used?
Which test type is the most accurate and sensitive?
Why is GC-MS not used as often?
Time-consuming and costly
What are the s/sx of opioid overdose?
Decreased RR and bowel sounds
Depressed mental status
What opioids can cause serotonin syndromes or seizures?
What opioids can cause hepatotoxicity?
What opioids can cause QTc prolongation?
What is the management of opioid overdose?
Tox panel, CPK, electrolytes, glucose, ECG
What is the goal RR for naloxone administration?