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How do IV and IM opioid dosage forms compare?
IV requires lower and more frequent dosing compared to IM
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What drugs are available for Neuropathic Pain?
Gabapentin
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Gabapentin has a Starting and Maintenance dose of:
- 100 mg PO three times daily
- Maintenance dose is 900-3600 mg/day in 3 divided doses
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When should you adjust the dose of Gabepentin?
Adjust dose for renal function
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What are the SE of Gabapentin?
Causes a lot of edema
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_____________can be used instead of Gabapentin, because it doesn’t cause as much edema.
Pregabilin
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Carbamazepine is Rarely used, why?
Many drug interactions – inducer
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______ or _________may be used as adjuncts to opioids in select patients.
NSAIDs or APAP
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NSAID use limited by risks of:
- Surgical site bleeding
- GI bleeding
- Delay in bone healing
- Development of acute kidney injury
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Ketorolac should be limited to max of __ days with close monitoring for _____________ or ___________..
- 5
- renal insufficiency or GI bleeding
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Acetaminophen used as antipyretic, may have _________________effect.
opioid sparing
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Ketorolac (Toradol) comes in what dosage forms?
IM or IV
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_____________comparable to moderate doses of morphine or meperidine.
Ketorolac (Toradol)
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What is the onset for Ketorolac (Toradol)?
Onset is 10 minutes
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What is the Dose for Ketorolac (Toradol) in < 65 yrs? IM or IV: 15-30 mg q 6h (Max 120 mg/day)
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Ketorolac (Toradol) si Contraindicated for:
Peri-op pain of CABG surgery
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What are the SE of Ketorolac (Toradol)?
- Renal effects and package labeling
- Serious GI toxicity
- Bleeding, ulceration, perforation in elderly
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What is the name of IV Ibuprofen?
Caldolor
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What are the indications for IV Ibuprofen (Calodor)?
Indicated for fever, mild to moderate pain, or as adjunct to opioids in adults
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IV Ibuprofen (Calodor) has a boxed warning for what?
Boxed Warnings for cardiovascular and GI risk ( especially with CABG)
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What are the Contraindications of IV Ibuprofen (Calodor)?
- Asthma, urticaria, or allergic-type reactions after taking aspirin or other NSAIDs
- Peri-operative period in the setting of coronary artery bypass graft (CABG) surgery
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What are the most common adverse reactions of IV Ibuprofen (Calodor)?
Nausea, flatulence, vomiting, headache, hemorrhage and dizziness (>5%)
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What are the DDI’s associated with IV Ibuprofen (Caldolor)?
Drug interactions: ACE inhibitors, aspirin, warfarin, lithium, diuretics
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What is the Pain dose of IV Ibuprofen (Calodor)?
400 mg to 800 mg intravenously over 30 minutes every 6 hours as necessary
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What is the fever dose of IV Ibuprofen (Calodor)?
400 mg intravenously over 30 minutes, followed by 400 mg every 4 to 6 hours or 100-200 mg every 4 hours as necessary
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What should the Infusion time for IV Ibuprofen (Calodor) be?
Must be no less than 30 minutes
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What is the Max dose of IV Ibuprofen (Calodor)?
3.2 grams/day
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Acetaminophen PO/PR has what OOA?
Onset is 30-60 minutes (variable)
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What is the Dose of Acetaminophen PO/PR ?
- 325 – 1000 mg ever 4-6 hours
- Max dose is ≤ 4 g/day
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IV Acetaminophen (Ofirmev) has what Indications?
- Management of mild to moderate pain
- Management of moderate to severe pain with adjunctive opioid analgesics
- Reduction of fever
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What is the normal Dose of IV Acetaminophen (Ofirmev) in adults and adolescents > 50 kg?
- 1000 mg IV every 6 hours or 650 mg IV every 4 hours to a maximum of 4000 mg per day ( GIVE 4 grams for IV, don’t do the 3 grams that is only for the oral products)
- Minimal dosing interval at 4 hours
- May be given as single or repeated dose
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What are the Side effects of IV Acetaminophen (Ofirmev)?
- ≥ 3% nausea, vomiting, headache, insomnia
- All similar incidence to placebo
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IV Acetaminophen (Ofirmev) Patient Selection includes:
- NPO
- Suspected ileus
- Avoid CNS depression
- Thrombocytopenia– allows us to avoid NSAIDs
- Renal dysfunction – allows us to avoid NSAIDs
- Opioid sparing effect
- Avoid NSAIDs
- Clinical Studies with IV Acetaminophen
- Pain – placebo controlled studies
- Ear, nose and throat surgery, spinal surgery, orthopedic surgery, GI surgery, gynecologic surgery, urologic surgery
- Adenotonsillectomy
- Cardiac surgery, hernia repair, orthopedic surgery, gynecologic and obstetric surgery, ear, nose and throat surgery, dental surgery
- Fever
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Indications for NMBs:
- Facilitate mechanical ventilation – Biggest reason
- Manage increased intracranial pressure
- Treat muscle spasms
- Neuroleptic malignant syndrome
- Decease oxygen consumption
- Stop seizure activity
- Avoid self injury
- Severe acute respiratory distress syndrome
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What are the Neuromuscular Blocking (NMB) Agents, Depolarizing Agents:
- Succinylcholine
- Short acting
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What are the Neuromuscular Blocking (NMB) Agents, Nondepolarizing Agents:
- Atracurium (Tracrium)
- Cisatracurium (Nimbex)
- Rocuronium (Zemuron)
- Vecuronium (Norcuron)
- Pancuronium (Pavulon)-Long acting
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All NMBs LACK ___________,______________ and _____________PROPERTIES
SEDATIVE, AMNESTIC, AND ANALGESIC
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What is the MOA of NMB Depolarizers?
Mimic ACh; cause sustained depolarization with block of neurotransmission
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What is the MOA of NMB Nondepolarizers?
Bind to ACh receptor and block transmission
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What is Succinylcholine (Anectine) used for and why
- Used to facilitate intubation
- Ultra-short acting
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What are the SE of Succinylcholine (Anectine)?
- Muscle fasciculations (jerky)
- Caution for hyperkalemia – HAVE TO KNOW THEIR K LEVELS
- May increase serum potassium by 0.5 to 1.0 mEq/L due to EFFLUX OF POTASSIUM FROM MUSCLE CELLS
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___________________________ is an Isomer of atracurium with three times its potency.
Cisatracurium (Nimbex)
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______________________ is Degraded by pH- and temperature-dependent Hoffman elimination
Cisatracurium (Nimbex)
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__________________________ has no adverse effect >1% in clinical trials.
Cisatracurium (Nimbex)
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Can cisatracurium (nimbex) be used with hepatic and renal insufficiency?
Yes
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What does a Peripheral Nerve Stimulator do?
Monitors whether a patient is blocked
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Dosing of NMB is based upon:
Clinical judgment and discretion of nurse in past
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Peripheral nerve stimulator objectively assesses:
- The degree of blockage
- helps guide optimal dose of NMB
- thumb adduction caused by contraction of the adductor pollicis in response to stimulation of the ulnar nerve is the most widely used electrode placement
- train of four quantifies the range of depth of NMB
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Doses of NMB should be titrated to achieve:
- One or two twitches on train-of-four and desired clinical effect
- Train of four pulses where each is 0.5 seconds apart
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One to two twitches corresponds to ___-___% blockade
85-90
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Train Of Four should be assessed how often?
Several times per day
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________ is used to ensure adequate sedation and assess need for continued paralysis.
Drug holiday
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What are the risks of NMBs?
- Complications From NMBs
- Critical illness polyneuropathy
- Prolonged recovery/deconditioning – GET WEAK
- Accumulation of NMBs or metabolites
- Diffuse weakness that persists long after the NMB is discontinued
- Keratitis and corneal abrasian
- Myositis ossificans (heterotropic ossification)
- Tachyphylaxis
- Increased risk of VTE
- Skin breakdown and decubitus ulcers
- Atelectasis/aspiration/pneumonia
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Medications that Potentiate NMBs include:
- Corticosteroids
- Aminoglycosides
- Clindamycin
- Colistin
- Type Ia Antiarrhythmics (and magnesium)
- Calcium channel blockers and ß-blockers
- Chemotherapy (cyclophosphamide)
- Dantrolene
- Furosemide
- Lithium
- Cyclosporine
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Medications that Antagonize NMBs include:
- Phenytoin
- Carbamazepine
- Theophylline
- Sympathomimetic agents
- Chronic exposure to NMBs
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Conditions that Potentiate NMBs include:
- Hypothermia
- Acidosis
- Myasthenia gravis
- Neoplastic syndrome
- Muscular dystrophies and myotonia
- Multiple sclerosis
- Amyotrophic lateral sclerosis
- Acute intermittent porphyria
- Electrolyte disturbances
- Hyponatremia
- Hypocalcemia
- Hypokalemia
- Hypermagnesemia
- Renal failure
- Liver failure
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Conditions that Antagonize NMBs:
- Hypercalcemia
- Hyperkalemia
- Endotoxemia and sepsis
- Major burns and trauma
- Hepatic failure with ascites
- Denervation syndrome
- Hemiplegia
- Peripheral neuropathies
- Diabetes
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What are the main Agents for sedative and amnestic effects?
lorazepam, midazolam
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What are the main Analgesic agents?
fentanyl, morphine, hydromorphone
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What are the main Delirium in the ICU patient?
haloperidol (Haldol), quetiapine (Seroquel)
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