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Flashcards in Acute Pain Deck (72):
1

What is ketorolac?

Very potent NSAID

2

What is the onset of analgesia for ketorolac?

30 min

3

What is the peak effect of ketorolac?

2-3 hours

4

What is the duration of ketorolac?

4-6 hours

5

When is ketorolac contraindicated?

Labor and delivery

6

What do all NSAIDs increased the risk of in post-op CABG surgery?

MI and Stroke

7

What are the 3 IV opioids?

Morphine
Hydromorphone
Fetanyl

8

Which IV opioid accumulates in renal impairment?

Morphine

9

How does morphine cause hypotension?

Histamine release

10

What is a good IV alternative for morphine-intolerant pts?

Hydromorphone

11

What do all IV opioids cause?

Hypotension

12

What is similar to fentanyl in potency and PK parameters?

Remifentanil

13

What kind of metabolism does remifentanil show?

Organ-independent

14

When is meperidine used?

Labor and delivery
Reduce rigors associated w/amphotericin toxicity

15

What may be found PRN on a chart if the patient is receiving IV opioids?

Naloxone

16

Why does naloxone require repeated doses?

Short 1/2 life elimination compared to opioids

17

What is the onset of IV naloxone?

2 min

18

Who should not receive PCA?

Dementia
Delirium
Cognitive deficits
H/o substance abuse
Anticipated short duration of opioid use

19

Who has an indication for PCA?

Post-op pain
Severe pain
Cancer pain
Sickle cell crisis
Palliative care
Burn pts

20

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

21

What is the first step in adjusting PCA in opioid-naive patients?

Increase dose first

22

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

23

How do we adjust PCA doses in opioid tolerant patients?

Increase basal rate up to 2/3 of average hourly usage

24

How do we start PCA in a opioid tolerant patient?

Will likely need basal rate and higher PCA dose

25

What are ways to administer spinal opioids?

Epidural
Intrathecal

26

When is neuraxial analgesia indicated?

Post-op pain
Labor and delivery
Chronic pain

27

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

28

How does the drug that is administered via an epidural make it into the CSF?

Drug diffuses through the dura into the CSF

29

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
-Contains CSF

30

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

31

What are the approximate equivalencies of morphine from an IV to epidural to intrathecal dose?

10mg IV = 1mg epidural = 0.1mg intrathecal

32

Which opioids used in neuraxial analgesia are highly lipid soluble?

Fentanyl
Sufentanil

33

Which opioids used in neuraxial analgesia have lower lipid solubility?

Morphine
Hydromorphone

34

Which neuraxial analgesics have a rapid onset of analgesia?

Fentanyl
Sufentanil

35

Which neuraxial analgesics have a delayed/slower onset of analgesia?

Morphine
Hydromorphone

36

Which neuraxial analgesics are more rapidly cleared from the CNS?

Fentanyl
Sufentanil

37

Which neuraxial analgesics have a prolonged half life in the CNS?

Morphine
Hydromorphone

38

What is a serious AE of neuraxial analgesics?

Hematoma formation

39

What increases the risk of a hematoma formation?

Anticoagulants
Antiplatelets

40

When is the risk of a hematoma forming greatest?

During placement/removal of catheter

41

When is neuraxial analgesia contraindicated?

Uncorrected coagulopathy
Infection of the lower back
Uncorrected hypovolemia
Increased intracranial pressure

42

What type of solution must intrathecal and epidural agents be?

PF

43

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

44

What is the definition of tolerance?

The reduction of drug effect over time as a result of exposure to the drug

45

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

46

What is the definition of addiction?

Ongoing substance use despite known harmful consequences to health or relationships

47

What is the definition of pseudoaddiction?

Person exhibits behaviors suggestive of addiction but in reality are a reflection of unrelieved pain

48

How long until a patient has physical and psychological opioid dependence?

Approximately 3 weeks of daily opioid use

49

What are the sx of WD after 3-4 hours of non-use?

Drug craving
Anxiety
Fear of WD

50

What are the sx of WD after 8-14 hours of non-use?

Anxiety
Restlessness
Insomnia
Rhinorrhea
Lacrimation
Diaphoresis
Stomach cramps
Mydiasis

51

What are the sx of WD after 1-3 days of non-use?

Tremors
Muscle spasms
Vomiting
Diarrhea
Tachycardia
Chills

52

What opioids can be given to treat acute WD?

Any

53

What is the new term for detoxification?

Medically supervised WD

54

What drugs should be used for detox?

Suboxone
Buprenorphine
Methadone

55

What medications can be used for sx relief in detox?

Clonidine
Benzo
Loperamide
Anti-emetics

56

What is the length of time for drugs of abuse that can be detected in the urine?

About 48 hours

57

How do we evaluate a urine sample?

Appearance and color
Temperature
Volume
Concentration of urine
Urine pH, specific gravity, CrCl

58

What are the two types of urine tests?

Immunoassay
Gas chromatography-mass spectrometry (GC-MS)

59

What is the most common initial urine test?

Immunoassay

60

How does immunassay work?

Uses antibodies to detect the presence of parent drug or metabolites

61

What is a negative about immunoassays?

False positives can occur d/t other substances

62

If a patient's immunoassay tests positive, does that mean that they took something?

No, it is presumptive

63

When is the GC-MS used?

Confirmation purposes

64

Which test type is the most accurate and sensitive?

GC-MS

65

Why is GC-MS not used as often?

Time-consuming and costly

66

What are the s/sx of opioid overdose?

Decreased RR and bowel sounds
Miosis
Depressed mental status

67

What opioids can cause serotonin syndromes or seizures?

Meperidine
Tramadol

68

What opioids can cause hepatotoxicity?

APAP combinations

69

What opioids can cause QTc prolongation?

Methadone
Oxycodone

70

What is the management of opioid overdose?

ABCs
Secure airway
Administer naloxone
Tox panel, CPK, electrolytes, glucose, ECG

71

What is the goal RR for naloxone administration?

12+ BPM

72

What are preventative techniques for opioid overdose?

Prescription Drug Monitoring Programs
Abuse-deterant formulations (ER)
Civilian access to naloxone