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Flashcards in pain Deck (33):
1

JCAHO changed pain management

mandation: need to document pain, tx

2

mech of pain management: #1

remove cause

3

mech of pain management: dec. inflammation, irritation, sensitivity of nerve endings

aspirin (prototype NSAID), NSAIDs

4

mech of pain management: block conduction of impulses by pain fibers

local anesthetics (lidocaine)

5

mech of pain management: modify processing of pain info in CNS

opioids: morphine
others: aspirin, acetominophen, NSAIDS

6

aspirin, ibuprofen, NSAIDs work via

-inhib. prostaglandin synthesis (COX-1, COX-2)
-alleviate pain by acting at nerve endings and in CNS
-antiinflammatory effects contribute to pain relief
*pain relieving dose is less than anti-inflammatory dose*


7

aspirin, ibuprofen, NSAIDs side effects

GI: irritation, bleeding
CV: HTN, MI, stroke

8

pain pathway

nociceptors-->afferent fibers-->DRG-->substantia gelatinosa-->STT-->thalamus-->TO BOTH: sensory cortex (feel the pain) and limbic system (emotional response)

9

pain mediators

endorphins, enkephalins, serotonin, NE, substance P, prostaglandins

10

opioids work primarily on the...

limbic system; pain does not cause as much distress

11

acetaminophen works via

inhib. PG syn. in CNS nerve endings (*not in periphery*)
also alleviates pain at nerve endings in CNS (unclear mech)

12

acetaminophen does NOT

affect inflammation
cause GI irritation

13

acetaminophen risks

hepatotoxicity at high doses (4 g/day)
*not only a problem with OD, ALSO with moderate doses if other risk factors (hepatitis, etOH) (2.5-3 g/day)

14

NSAIDs also have

anti-pyretic activity (lower fever)

15

*Ketorolac (Toradol)*

*ACUTE pain management* (not as much for anti inflammatory)
musculoskeletal, post-op, visceral (kidney stone, gall bladder stones)

injectable NSAID
-alt. to opioid for pain

16

selective COX-2 inhibs action

prev. anti-inflammatory affects w/out red. in COX-1 activity (important prostaglandins in upper GI "good guys" that inhib. acid prod. and is mucus producing)

17

selective COX-2 inhibs

celocoxib (Celebrex) -not as bad SE as other 2
rofecoxib (Vioxx)
valdecoxib (Bextra)

18

COX-2 is not always bad

maintain renal perfusion (COX-1)
produce prostacyclin:
vasodilate coronary vessels & inhibit plateled aggretation

19

even selective COX-2 inhibitor use can cause

inc. renin-->inc. aldosterone-->inc. Na retention-->*HTN* (COX-1 as well)

prostacyclin prod. prevented-->coronary
constriction and uninhibited platelet aggregation-->coronary HTN, heart attack, stroke

20

NSAIDs and etOH

contribute to HTN

21

problems with Ketorolac (Toradol)

causes GI irritation *one of the worst!*
ok for short term (1-2 days) not chronic

22

local anesthetics

-block sodium channels in nerve endings and axons and stop gen/cond of APs
small unmyelinated neurons are most sensitive
(type C pain fibers)
high enough conc. can affect motor neurons: spinal, regional, nerve block techniques
invasive procedures-->affect motor function and sensory modalities

23

newer low dose protocols of local anesthetics

more selective pain relief withough affecting other functions (+influsion pumps)

24

opioids

most effective drugs for sev. pain
under-utilized bc of legal issues and fear of addiction
-this should not prevent use for app. pain management

25

opiod receptors

u agonists are most powerful: morphine, hydromorphone, less: pentazocine, Buprenorphine
kappa: pentazocine, nalbuphine
gamma:
MORE

26

u agonists also...

have greatest abuse potential (euphoria)

27

scheduling of controlled substances

analyze medical benefits vs physical dependence

28

Schedule 1 opioids:

heroine, etc *DO NOT PRESCRIBE*

29

Schedule 2 opioids:

morphine, dilaudid, percusate (hydrocodone) 30 day supply, non-refill
*high abuse potential* req. to be reported
can
must be taper prescriptions
can pre-prescribe

30

Schedule 3 opioids:

codeine (used for mild-mod pain
vicodin (hydrocodone+ acetominophen) moved from 3 to 2!!
6 month refill potential at 1 month increments

31

vicodin

5 mg hydrocodone + 500 mg acetaminophen (do not exceed 8/day)

32

if sev. pain

stay away from combo products MORE

33

pain management & cost effectiveness

cost of appropriate pain management easy to consider
-not so easy: *cost of inadequate pain management*: ER visits, surgery, negative effect on life