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Pharmacotherapy for Acute Pain:

Implications for Practice

Dina A. Krenzischek, MAS, RN, CPAN, Colleen J.


Dunwoody, MS, RN-BC,
Rosemary C. Polomano, PhD, RN, FAAN, James P.
Rathmell, MD

2008 by American Society of PeriAnesthesia Nurses

報告者: 洪一仁藥師
Outlines
• Introduction
• NSAIDs
• Opioids
• Specific Opioid-Related
Pharmacological Issues
• Local anesthetics
Introduction
Definition of pain
• Once thought to be a punishment from the gods,
the word is derived from the Latin peone and the
Greek poine, meaning “penalty” or “punishment.”

• “An unpleasant sensory and emotional


experience associated with actual or potential
tissue damage or described in terms of such
damage.”

• Many clinicians define pain as whatever the


patient says it is.
Classification of pain
• Nociceptive pain
- Acute pain.
- Somatic or visceral.

• Neuropathic pain
- Chronic pain
- Nerve damage.
Nociception
• Stimulation
• Transmission
• Modulation
• Perception
NSAIDs
Pharmacological Properties

• Prostaglandins sensitize nociceptors to mechanical and


chemical stimuli by lowering the stimulatory threshold of C-
fiber polymodal nociceptors.

• NSAIDs exert their action on dorsal horn cells of the spinal


cord to decrease reactive hyperalgesia or increase
thresholds for sensitivity to pain that may occur in response
to peripheral inflammation.

Hyperalgesia
– A state where a painful stimulus cause more pain than
normally expected
Use in Perioperative Analgesia
• NSAIDs are are not as effective for visceral pain
originating from nociceptors in the organs and
linings of the body cavities.

• NSAIDs are often given in combination with an


opioid in patients with moderate to severe acute
pain following surgery.

• Selective COX-2 inhibitors are associated with a


reduction in postoperative opioid use, a decrease
in opioid-induced complications, and an increase
in patient satisfaction. - AANA J. 2006
Lonine 200mg

Purfen 400mg

Suloril 100mg

Volna-k 25mg
Flamquit 50mg
Opioids
Pharmacological Properties
• Opioid receptors are located on cells throughout
the peripheral and central (spinal cord and brain)
pain pathways.

• Inhibition of nociception, or sensing of pain, in


the dorsal root ganglia of the spinal cord.

• Activation of descending pain pathways


controlled by circuits from the forebrain and
midbrain.
Use in Perioperative Analgesia
• Opioids are more effective for continuous and
dull pain rather than sharp, intermittent pain.

• Morphine and other μ receptor agonists (eg,


hydromorphone, fentanyl, and oxycodone)
produce analgesia, changes in mood,
drowsiness, and clouding of consciousness
without producing unconsciousness.
Specific Opioid-Related
Pharmacological Issues
• Exposure to a new opioid in the same equianalgesic
dosing range may produce significant side effects.

• Lower doses of the calculated equianalgesic dose of the


new opioid, approximately 25%~50% less, should be
given as the initial dose

• This initial dose can then be titrated up by increments of


25%~50% daily as tolerated to achieve optimal pain
control.

• Equianalgesic doses should be calculated for 24-hour


usage rather than per dose, and the calculation should
also include a rescue dose of 15%~20% of the 24-hour
dose.
Avoiding Meperidine
• Once a popular opioid for the treatment of
postoperative pain, has analgesic and sedative
properties similar to morphine.

• Meperidine is no longer recommended for the


treatment of acute pain and has no place in the
management of chronic pain. It has significant
neurotoxicity, manifested by tremors,
hyperactive reflexes, and seizures. These
adverse effects result from accumulation of
normeperidine, a CNS toxin

• Patients with renal or hepatic impairment are at


increased risk for neurotoxicity.
Local anesthetics
Pharmacological Properties
• Local anesthetics act to block the voltage-
gated Na+ channels, raise the threshold for
excitability, slow propagation of the action
potential, and eventually prevent
transmission of nerve impulses.
Use in Perioperative Analgesia
• Local anesthetics are administered via epidural
catheters and regional catheters for nerve
blocks to interfere with or block the transmission
of pain.

• With epidural analgesia, local anesthetics are


often administered in combination with an opioid,
but sometimes a local anesthetic is given alone.
Safety Concerns
• 6 major adverse reactions to local anesthetics
which include cardiac dysrhythmias, hypertension,
direct tissue toxicity, central nervous system
toxicity (eg, including dizziness, light headedness,
paresthesias, nervousness, disorientation,
seizures, coma, and even respiratory arrest),
methemoglobinemia, and allergic reactions.

• Bupivacaine appears to be associated with the


most serious cardiac dysrhythmias
Reference
1. Muhammad A. Munir, MD, Nasr Enany,
MD,Jun-Ming Zhang, MSc, MD. Nonopioid
Analgesics. Med Clin N Am 91 (2007) 97–111
2. Joseph Ming Wah Li, MD. Pain Management
in the Hospitalized Patient. Med Clin N Am 92
(2008) 371–385
3. UpToDate . Overview of the treatment of
chronic pain
4. Rakel & Bope: Conn's Current Therapy 2008,
60th ed.
5. Rakel: Textbook of Family Medicine, 7th ed.
Thank you~