Professional Documents
Culture Documents
PAIN MANAGEMENT
Objectives
Psychological:
Anxiety, Depression, Fatigue
The Hospital
DO NO HARM
Effective
Analgesic
Modalities
KEY POINTS
Pain Pathways
Opioids
Local Anesthetics
NMDA antagonists
Ketamine, dextromethorphan
Tissue Trauma
Cell Membrane Phospholipids
Phospholipase
Arachidonic Acid
C
O
X
Cyclo-oxygenase
Endoperoxides
Thromboxane
Prostaglandins
Solution?
Between a rock and a hard place! as far as the
use of opioids goes.
Side-effects
Analgesia
Multi-modal Analgesia
Side-effects
Analgesia
Gun,
Case Problem:
Severe Respiratory
Depression after Toradol?
Case Problem:
Severe Respiratory
Depression after Toradol?
Pain
Opioid
Side-effects
Resp Depression
Analgesia
Opioid
No
Cyclo-oxygenase inhibitors
Concept # 2
All patient having surgical procedures
associated with post-operative pain should
receive a pre-emptive COX inhibitor,
provided there are no patient contraindications.
COX-2 for everyone probably the safest
and easiest to organize.
The Opioids
We
Meperidine
75 mg
IM Q4H
prn
Tylenol #3
1 2 PO
Q4H
prn
Opioids
What are the factors that determine the
dose of opioid we choose?
Opioids
The dose of opioid administered is
dependant upon multiple factors
Pharmacological tolerance to opioids?
Route of administration
PO, IM/SC, IV bolus, intrathecal
Age
Weight
Severity of pain
Opioids
Opioids
Pharmacokinetic + Pharmacodynamic
patient to patient variability results in1000 %
variability in opioid dose requirements
Concept # 1
opioid dosage must be individualized
IV PCA:
morphine
golden standard, pruritus a common problem
meperidine
a little faster onset than morphine
normeperidine a toxic metabolite is a problem for
patients with decreased renal function or using large
dosages for more than a few days
hydromorphone
less confusion in elderly patients?
dose
Lock-out Interval
Continuous infusion
One hour max. limit
Opioids
Issue
With parenteral opioids the patient may experience intolerable side
effects before adequate analgesia is attained
Opioids
CONCEPT # 2
Targeted regional
administration of opioid
results in enhancement of
the therapeutic index (ratio
of analgesia/side effects)
is a pro-drug
4 grams/day = 12 tabs/day
12 X 30 mg = 360 mg codeine = 60 mg morphine
60 mg PO = 15 30 parenteral morphine
Equals about 1 mg/hr IV/s.c.
Adequate for moderate pain in average patient?
T#3
T#3
Oxy
5 mg
Long Acting
Opioid
Opioids
CONCEPT # 3
Under utilization of high efficacy PO opioids
morphine 20 mg
hydromorphone 4 mg
oxycodone 10 mg
codeine 120 mg
meperidine 200 mg
Opioids
Dilaudid 1 4 mg PO/IM/IV Q4H prn
NOT!
This represents up to 30 fold range in
peak effect in any given patient
1 mg PO ---- 4 mg IV bolus
homeopathic dose ---- potentially lethal
Foundation of Acetaminophen/COX-inh.
Dextromethorphan
Concluding Remarks
The foundation of all acute pain Rx
protocols is a COX-Inhibitor
Limitations of Tylenol # 3
Texts
Managing
Professionals Reference
Edited by Roman Jovey MD
Endorsed by the CPS
Available free from Purdue Pharma