analgesia in oral surgery Flashcards

Question

groups of people to have caution/avoid giving aspirin

Answer 1

1. Peptic ulceration 2. Epigastric pain 3. Bleeding abnormalities 4. Anticoagulants 5. Pregnancy/breast feeding 6. Patients on steroids 7. Renal/hepatic impairment 8. Children and adolescents under 16 years 9. Asthma 10. Hypersensitivity to other NSAIDs * *Aspirin is an NSAID* 11. Taking other NSAIDs 12. Elderly * *Generally careful in elderly with all medications* 13. G6PD-deficiency

Answer 2

gastric or duodenal bleeding could result in perforations

Answer 3

history of epigastric pain/discomfort or gastro-oesphageal reflux but no ulcer diagnosed

Answer 4

have known bleeding problems e.g. haemophilia * high risk of bleeding - don't want to exacerbate

Answer 5

* Aspirin enhances warfarin and other coumarin anticoagulants * Displaces warfarin from binding sites on plasma proteins * Increases free warfarin * The majority of warfarin is bound (inactive), if more is released this will become active increasing bleeding tendency

Answer 6

* Especially 3^rd trimester * This is nearer delivery and may cause impairment of platelet function *(Aspirin has antiplatelet property)* * Increased risk of haemorrhage * Increased risk of jaundice in baby * Can prolong/delay labour (unsure why) * Contraindicated in breastfeeding -\> Reye’s syndrome

Answer 7

* Aspirin metabolism is in liver and excretion mainly in kidney * If renal impairment = excretion may be reduced/delayed * Not a complete contraindication but administer with care/reduce dose and avoid if renal or hepatic impairment severe ## Footnote *Always caution renal and hepatic – most Mx metabolised in liver and excreted by kidney – like aspirin*

Answer 8

Prostaglandins PGE₂ and PGI₂ are powerful vasodilators synthesised in the renal medulla and glomeruli respectively, * are involved in the control of renal blood flow and excretion of salt and water inhibition of renal prostaglandin synthesis may result in: * sodium retention * reduced renal blood flow * renal failure NSAID may cause interstitial nephritis and hyperkalaemia * Prolonged analgesic abuse over a period of years is associated with papillary necrosis and chronic renal failure * Severe derangement of pt urea and electrolytes

Answer 9

* sodium retention * reduced renal blood flow * renal failure

Answer 10

Reye’s syndrome * Rare * Under 20s affected mainly * Very serious, up to 50% mortality * Related to brain damage due to encephalopathy * Fatty degenerative process in liver (and lesser extent kidney) * Profound swelling in brain * Clinically * Initially nausea, vomiting, lethargy * Later seizures and coma Contraindicated if under 16 years or breastfeeding Avoid during fever or viral infection in adolescents

Answer 11

* NSAID not completely contraindicated as some asthmatics have no problems with them * ask if used before and if any problems * any shadow of doubt avoid NSAIDs

Answer 12

* contraindicated in pts with a history of hypersensitivity to Aspirin or any other NSAIDs * this includes those in whom attacks of asthma, angioedema, urticaria or rhinitis have been precipitated by aspirin or any other NSAID

Answer 13

* combination of NSAIDs will increase risk of side effects * e.g. the combination of an NSAID and low dose aspirin may increase the risk of GIT side effects; and should be used if absolutely necessary and the pt monitored closely

Answer 14

* more susceptible to drug induced side effects in general * they are often smaller/smaller circulating blood volume * on other medications * Higher risk interactions when polypharmacy * Have other medical problems

Answer 15

glucose 6-phosphate dehydrogenase deficiency Rare Prevalent In individuals from: * Most parts Africa, * Most parts Asia * Oceania * Southern Europe Inborn error of metabolism, predisposes RBC breaking down

Answer 16

Inborn error of metabolism, predisposes RBC breaking down Susceptible to develop acute haemolytic anaemia on taking a number of common drugs * Aspirin – possible risk of haemolysis in some G6PD-deficient individuals (acceptable up to a dose of at least 1g daily in most G6pD-deficient individuals)

Answer 17

1. Children and adolescents under 16 years; breast feeding (Reye’s syndrome) 2. Previous or active peptic ulceration 3. Haemophilia 4. Hypersensitivity to aspirin or any other NSAID

Answer 18

* Thrombotic cerebrovascular/cardiovascular disease *(HA, stroke)* * A single dose of aspirin (150-)300mg given as soon as possible after ischaemic event, provided no contraindications * Maintenance treatment: 75mg daily

Answer 19

prescribe with PPI to protect (lansoprazole capsules, 15mg; gastro-resistant omeprazole capsules, 20mg) * 5 day regime usually

Answer 20

Used more commonly than aspirin in dentistry * Long term use recently associated with increased risk of cardiac events NSAID Available over the counter Popular as post-operative analgesia following oral suragery Paediatric suspension available * Safely given to children

Answer 21

Similar but not identical effect as aspirin Less effect on platelets Not used therapeutically for this - Not used for MI or stroke Irritant to gastric mucous – but lower risk than aspirin May cause bronchospasm (care in asthmatics but not completely contraindicated)

Answer 22

iburpofen tablets, 400mg * 1 tablet, 4 times a day, preferably after food ' send 20 tablets (last 5 days)

Answer 23

1. Previous or active peptic ulceration 2. The elderly 3. Pregnancy and lactation 4. Renal, cardiac or hepatic impairment 5. History of hypersensitivity to aspirin and other NSAIDs 6. Asthma 7. Patient taking other NSAIDs 8. Patient on long term systemic steroids

Answer 24

**GIT discomfort**, occasionally bleeding and ulceration **Hypersensitivity** reactions e.g. rashes, angioedema and bronchospasm * Others – headache, dizziness, nervousness, depression, drowsiness, insomnia, vertigo, hearing disturbance/tinnitus, photosensitivity, haematuria, blood disorders, fluid retention, renal impairment, hepatic damage, pancreatitis, eye changes, Steven- Johnson (rare and severe) and more, see BNF

Answer 25

* ACE inhibitors Beta blockers Other analgesics* * Cytotoxics Antibiotics Cardiac glycosides* * Anticoagulants Cyclosporin Antidepressants* * Clonidine Antidiabetics Clopidogrel (antiplatelet)* * Corticosteroids Lithium Calcium channel Blockers* * Diuretics Tacrolimus Vasodilator Antihypertensives* Many interactions - check BMF

Answer 26

* Rare but be aware of esp for emergency pts (more serious toxicity very uncommon) Symptoms * Nausea * Vomiting * Tinnitus A&E * Activated charcoal followed by symptomatic measures are indicated id more than 400mg/kg been ingested within the preceding hour * Absorb excess

Answer 27

* GP14 (Scotland) * FP10D (England) * WP10D (Wales) [https://bnf.nice.org.uk/guid ance/prescription-writing.html](https://bnf.nice.org.uk/guid%20ance/prescription-writing.html) No hospital labels on prescription * write out – confirm with pt to ensure correct Most dental tx 5 days * e.g. 400mg ibuprofen tables* * 3 times a day for 5 days* * Send 15 tablets*

Answer 28

NSAIDs inhibit cyclo-oxygenases and so reduce prostaglandins (which sensitise the tissues to other inflammatory mediators resulting in pain). inhibit COX-1 as well as COX-2 * Predominantly COX-1 inhibition * Aspirin 150 times more effective at inhibiting COX-1 than COX-2

Answer 29

cyclo-oxygenase predominantly responsible for catalysing the reaction that produces prostaglandins associated with: * Platelet aggregation * protection of gastric mucosa

Answer 30

Aspirin 150 times more effective at inhibiting COX-1 than COX-2 * Amount of Aspirin needed to have sufficient anti-inflammatory effects by inhibition of COX-2 will cause gastric damage due to the amount of COX-1 inhibition

Answer 31

* Pathological situation * Whether they are formed by COX-1 or COX-2 * Whether they are formed in excessive amounts e. g. PGE₂ generated in low physiological amounts by COX-1 in gastric tissues and has a protective effect * Prostaglandins (esp PGE₂) are generated in excessive amounts during inflammation via elevated COX-2 levels. PGE₂ in large amounts produces increased vasodilation, increased vascular permeability and sensitises pain fibre nerve endings to bradykinin, 5HT and other mediators

Answer 32

PGE₂ generated in low physiological amounts by COX-1 in gastric tissues and has a protective effect Prostaglandins (esp PGE₂) are generated in excessive amounts during inflammation via elevated COX-2 levels. * PGE₂ in large amounts produces increased vasodilation, increased vascular permeability and sensitises pain fibre nerve endings to bradykinin, 5HT and other mediators

Answer 33

less gastric effect ## Footnote Since the analgesic actions of NSAIDs appear to result from inhibition of COX-2 (mainly, although COX-1 can be involved *(but aspirin and ibuprofen more COX-1)*) it would make sense to have Selective COX-2 Inhibitors and spare COX-1

Answer 34

Celecoxib (celebrax) * Useful anti-inflammatory actions and fewer GIT damaging actions compared with non-selective NSAIDs Useful for rheumatoid arthritis

Answer 35

all NSAIDs inc selective COX-2 inhibitors

Answer 36

non-selective NSAIDs

Answer 37

do not use more than one oral NSAID at a time (inc selective COX-2 inhibitors) (dental and orofacial pain) – COX-2 selective should be chosen to manage dental pain only in pts at high risk of gastric or duodenal ulceration (e.g. those with a history of peptic ulcer)

Answer 38

* Highly selective COX-2 inhibitors do not have an effect on platelet aggregation and so may be better tolerated by patients with clotting disorders * Several COX-2 selectives have been withdrawn due to cardiovascular risk * Other COX-2 selective NSAIDs not withdrawn e.g. celecoxib – but no longer of the Dental List * So cannot prescribe as dentists – but if patient cannot have NSAIDs (ibuprofen or aspirin) may beconsidered if liaise with GMP

Answer 39

acetaminophen

Answer 40

simple analgesic without anti-inflammatory activtiy *NOT NSAID* * common * relatively safe

Answer 41

1. Analgesic 2. Antipyretic 3. Little or no anti-inflammatory action 4. No effect on bleeding time 5. Does not interact significantly with warfarin 6. Less irritant to GIT 7. Suitable for children

Answer 42

reduction in temperature

Answer 43

Hydroperoxides are generated from the metabolism of arachidonic acid by COX and exert a positive feedback to stimulate COX activity * This feedback is blocked by paracetamol, thus indirectly inhibiting COX – especially in the brain Results in: * Analgesia * Antipyretic action * No reduction in peripheral inflammation A small component of the analgesic action of all NSAIDs is the reduction of prostaglandins in the pain pathways of the CNS, such as in the thalamus * MAIN site of action of paracetamol - CENTRALLY – thalamus Alternative central mechanisms have also been proposed, inc reduced 5HT production or interference with the excitatory amino acid NMDA (N-Methyl-D-Aspartate) in spinal cord pathways * **Exact mode of action still unclear** Since paracetamol does not appear to have much effect on peripheral prostaglandins there is little/no gastric mucosal irritation * Described as ‘safe analgesic’ although causes severe problems in overdose

Answer 44

A small component of the analgesic action of all NSAIDs is the reduction of prostaglandins in the pain pathways of the CNS, such as in the thalamus * MAIN site of action of paracetamol * CENTRALLY – thalamus Since paracetamol does not appear to have much effect on peripheral prostaglandins there is little/no gastric mucosal irritation * Described as ‘safe analgesic’ although causes severe problems in overdose

Answer 45

1. Hepatic impairment 2. Renal impairment 3. Alcohol dependence

Answer 46

1. Rashes 2. Blood disorders 3. Hypotension reported on infusion (IV) 4. Liver damage (and less frequently kidney damage) following overdose – hepatotoxic in high doses

Answer 47

* Anticoagulants (prolonged regular use of paracetamol possibly enhances the anticoagulant effect of the coumarins) * Cytotoxics * Domperidone * Lipid-regulating drugs * Metoclopramide See BNF

Answer 48

500mg tablets; 1-2 tablets; 4 times a day (4-6 hourly) 8 x 500mg a day – max for adults (4g) *Children depends on age/weight*

Answer 49

Always warn pt with regard to maximum dose and emphasize that they should not exceed this * Overdose in emergency pts (extreme dental pain) As little as 10-15g (20-30 tablets) or 150mg/kg paracetamol taken within 24 hours may cause severe hepatocellular necrosis and less frequently renal tubular necrosis *(liver and kidneys)*

Answer 50

Anorexia, nausea, vomiting * The only early features of poisoning * Usually settle within 24 hours Persistence of these features beyond is often associated with abdominal pain (right subcostal pain and tenderness, usually indicates development of hepatic necrosis) * Liver damage is maximal at 3-4 days after ingestion and may lead to jaundice, renal failure, haemorrhage, hypoglycaemia, encephalopathy, cerebral oedema and death * Pain -\>develop into hepatic necrosis* * *Therefore, despite a lack of significant early symptoms – pts who have taken an overdose of paracetamol should be transferred immediately to hospital – liver risk*

Answer 51

contain paracetamol e.g. Lemsip, Co-codamol and co-proxamol

Answer 52

dihyrdrocodeine

Answer 53

* Act in spinal cord * Especially in the dorsal horn pathways associated with paleo-spinothalamic pathway * Central regulation of pain in: * Periaqueductal gey matter * Nucleus reticularis paragigantocellularis * Raphe magnus nucleus * They produce their effects via specific receptors which are closely associated with neuronal pathways that transmit pain to the CNS * Opioid is a term used for both naturally occurring and synthetic molecules that produce their effects by combining with opioid receptors BNF state – opioid analgesics are relatively ineffective in dental pain

Answer 54

dependece - *psychological and physical* tolerance - *only to depressant effects*

Answer 55

Psychological and physical * Withdrawal of the drug will lead to psychological cravings and the pt will also be physically ill

Answer 56

to achieve the same therapeutic effects the dose of the drug needs to be progressively increased

Answer 57

effects smooth muscles CNS effects

Answer 58

* Constipation (can occur after few doses of dihydrocodeine) * Urinary and bile retention ## Footnote *Long term opioid – uncomfortable*

Answer 59

* Depresses * Pain centre (alters awareness/perception of pain) * Higher centres * Respiratory centre * Cough centre *cough suppression* * Vasomotor * Stimulates * Vomiting centre * Dihydrocodeine often causes nausea and vomiting which limits its value in dental pain – not able to ingest drug fully * Salivary centre * Pupillary constriction

Answer 60

* Pain centre (alters awareness/perception of pain) * Higher centres * Respiratory centre * Cough centre cough suppression * Vasomotor

Answer 61

* Vomiting centre * Dihydrocodeine often causes nausea and vomiting which limits its value in dental pain – not able to ingest drug fully * Salivary centre * Pupillary constriction

Answer 62

The most common are nausea, vomiting and drowsiness Larger doses produce respiratory depression and hypotension (LBP) *Many more* * *Difficulty with micturition* * *Postural Hypotension* * *Uretic or biliary spasm* * *Hypothermia* * *Dry mouth* * *Hallucinations* * *Sweating* * *Dysphoria* * *Facial Flushing* * *Mood Changes* * *Headache* * *Dependence* * *Vertigo* * *Miosis* * *Bradycardia* * *Decreased libido or potency* * *Tachycardia* * *Rashes/urticaria/Pruritis* * *Palpitations*

Answer 63

* Hypertension * Hypothyroidism * Asthma * Decreased respiratory reserve * Prostatic hyperplasia * Pregnancy/breast feeding * Many precipitate come in hepatic impairment * reduce dose/avoid * Renal impairment * Reduce dose/avoid * Elderly and debilitated * Reduce dose * Convulsive disorders (epilepsy) * Dependence

Answer 64

unable to metabolism if liver not functioning

Answer 65

unable to excrete if kidneys not functioning

Answer 66

* Acute respiratory depression * Acute metabolism * Raised intracranial pressure/head injury * Interferes with respiration * Affects pupillary responses vital for neurological assessment

Answer 67

opioid analgesic A natural alkaloid found in opium poppy * 1/12^ththe potency of morphine * Still relatively strong Effective orally Lower dependence than morphine Usually in combination with NSAIDs or paracetamol * E.g. OTC 8mg codeine in 500mg paracetamol Prescription 30mg codeine in 500mg paracetamol *– not Dental list* Effective cough suppressant Common side effect – constipation Available over the counter

Answer 68

Only codeine combination on dental list is Dihydrocodeine ## Footnote *Codeine phosphate – not on dental list*

Answer 69

dihydrocodeine tartrate; DF118 Forte (trade name)

Answer 70

similar to codeine

Answer 71

* Sub cutaneous or intra-muscular (controlled drug) * Oral (not controlled)

Answer 72

* Controlled – need prescribed* * Not controlled - OTC*

Answer 73

Oral (only route on dental list) * 30mg every 4-6 hours as necessary 40, 60, 120mg not on dental list

Answer 74

General Opioid side effects (see side effects of codeine) * Nausea/vomiting * Constipation * Drowsiness Larger doses * Respiratory depression * Hypotension * Uretic spasm * Biliary spasm Etc

Answer 75

* Antidepressants MAOIs * Dopaminergic (Parkinsonism) many - see BNF

Answer 76

* Hypotension * Asthma * Pregnancy/lactation * Renal/hepatic disease * Elderly/children Remember – never prescribe in raised intracranial pressure/suspected head injury *see general opioid cautions*

Answer 77

* moderate to severe pain * However, BNF states that due to the side effects of nauseas and vomiting it is of little value for dental pain (pts look very pale and ill due to vomitting) * And not very effective for post-operative dental pain Not commonly prescribed by dentist

Answer 78

cause varying degrees of coma, respiratory depression and pinpoint pupils Specific antidote Naloxone indicated if there is coma or bradypnea * Naloxone has a shorter duration of action than many opioids * So, close monitoring and repeated injections/infusion may be necessary according to respiratory rate and depth of coma

Answer 79

* Trigeminal neuralgia * Post-herpetic neuralgia * Functional – TMJ or atypical facial pain

Answer 80

Carbamazepine * Proprietary brand e.g. Tegretol * Anti-convulsant - *Emergency – epilepticus* also used for trigeminal neuralgia

Answer 81

* Carbamazepine on Dental Practitioner’s Formulary Other drugs used for trigeminal neuralgia include: (not on dental list) * Gabapentin * Phenytoin

Answer 82

1. Severe spasms of pain – ‘electric shock’, lasts seconds 2. Usually unilateral *(One branch usually – but can be more)* 3. Older age group 4. Trigger spot identified e.g. *wash face, wind hit* 5. Females more than male 6. Periods of remission 7. recurrence of greater severity

Answer 83

100 or 200mg tablets Starting dose 100mg once or twice daily (some pts require higher initial dose) * Increase gradually according to response * Usual dose 200mg 3-4 times daily * Up to 1.6g daily in some patients (8 x 200mg) *Low dose and increase dose slowly*

Answer 84

Extensive list – see BNF e.g. * Dizziness * Ataxia * Drowsiness – issue in elderly as more susceptible to falls and brittle bones * Leukopenia and other blood disorders Patient blood monitoring – full blood count and liver function tests * Get pre-emptively so know in advance and monitor through Tx

Answer 85

1. AV conduction abnormalities (unless paced) 2. History of bone marrow depression 3. Porphyria

Answer 86

* Hepatic/renal/ cardiac disease *(metabolised by liver; excreted by kidney)* * Skin reactions * History of haematological reactions to other drugs * Glaucoma * Pregnancy/breast feeding * Avoid abrupt withdrawal

analgesia in oral surgery Flashcards

(113 cards)