Pain Pharmacotherapy, by Catherine Dowling.
Hi.
My name is Catherine Dowling.
I'm a nurse at Children's Hospital Boston in the cardiac ICU.
The objectives of this presentation are to understand the pharmacology of analgesia and
to recognize the complications of pain medication.
Non-narcotic Analgesics.
There are many options for pain control that do not involve narcotics.
Paracetamol is indicated for pain and/or fever.
It should be used with caution in patients with actual or potential liver dysfunction
since it is metabolized in the liver.
Ibuprofen is an oral non-steroidal anti-inflammatory agent indicated for pain, fever, and/or inflammation.
It should be used with caution in patients with actual or potential bleeding abnormalities
and renal dysfunction.
It is metabolized in the liver and excreted in the urine.
Toradol is a non-steroidal anti-inflammatory administered intravenously.
It is ideal for post-operative pain management in the patient without bleeding or renal dysfunction.
It is indicated for pain, fever, and/or inflammation.
It should be used with caution in patients with actual or potential liver dysfunction.
Narcotic Analgesics.
Morphine is a common opioid analgesic used in the cardiac intensive care unit.
It is metabolized in the liver and excreted in the urine.
Adverse effects include nausea, constipation, and respiratory depression.
It may cause a histamine release and local skin reaction during administration.
Fentanyl is a synthetic opioid analgesic indicated for pain management.
Infants may tolerate fentanyl better than morphine because there is no histamine release
with administration.
It is 100 times more potent than morphine.
Fentanyl is metabolized in the liver and excreted in the urine.
Rapidly-infused bolus doses may cause chest-wall rigidity.
As a precaution, have intubation equipment ready and administer muscle relaxants to reverse
chest-wall rigidity.
Methadone is indicated for opioid withdrawal.
It works as a substitute for opioid drugs such as morphine and fentanyl by producing
similar effects and preventing withdrawal symptoms.
Dosing and weaning should be monitored closely while watching for signs of withdrawal.
Weaning usually takes place in 10% increments.
Point of Clarification.
Methadone is no longer used as the primary medication for withdrawal management in the
pediatric population.
If the withdrawal assessment tool scores remain high during the weaning process, clonidine
should be considered first.
If the patient continues to show signs of withdrawal despite receiving clonidine, then
methadone may be considered.
Codeine is indicated for pain control in oral dosing.
It is metabolized in the liver and excreted in the urine.
Adverse effects may include nausea, constipation, dizziness, and drowsiness.
Point of clarification.
Please note that because of its pharmacology, the pain relief from codeine may be extremely
variable from patient to patient.
Sedatives.
Anxiety and pain are strongly related.
Individuals who experience high levels of anxiety also tend to have higher incidence
of pain.
Unrelieved pain has the potential to increase anxiety levels.
When a patient's stress level is high, it makes it more difficult to control the patient's
pain.
Sedatives relieve anxiety.
Chloral hydrate is used for medical procedures.
The onset of action is 15 to 30 minutes.
Adverse effects include excitability and uncooperativeness.
Excessive sedation may lead to respiratory depression.
Benzodiazepines are used as a hypnotic and anti-convulsant.
Negative effects include dose dependency, respiratory depression, hypotension, tolerance,
and withdrawal.
Benzodiazepines are a sedative used to treat anxiety and may be used in conjunction with
analgesics to treat pain.
Diazepam is used as a sedative, as well as an anti-convulsant.
It is an anti-anxiety agent and a hypnotic.
Midazolam can be used continuously or as an infusion with a short onset of action.
Lorazepam is indicated for long-term sedation and withdrawal management.
Anesthetic Agents.
Ketamine is indicated for short term anesthesia and analgesia, and for intensive care unit
procedures.
It is a rapid onset with a short duration of action.
Adverse reactions include hypertension, tachycardia, and hallucinations.
Propofol is indicated for intensive care unit procedures and peri-extubation.
Adverse reactions are pain at the injection site, hypotension, bradycardia, acidosis,
respiratory depression, and liver failure.
Propofol has a negative inotropic effect, therefore it should not be used with single
ventricle physiology or poor ventricular function.
Dexmedetomidine is used for sedating intubated and non-intubated patients.
It can be used prior to and during surgical procedures in intubated and mechanically ventilated
patients during treatments in the intensive care setting.
It should be administered by continuous infusion.
Side effects include hypotension and bradycardia.
It should be used wtih cautions in patients with ventricular dysfunction.
Side Effects.
Constipation, which can be severe, is a common problem for patients taking opioid pain medications.
This may be problematic even for patients taking the drugs over a short term.
Bowl regimens can be put in place to avoid the uncomfortable condition of constipation.
There are many options to help alleviate constipation, such as a stool softener.
A bowel stimulant will help alleviate the discomfort of constipation.
Nausea and vomiting are common side effects following opioid analgesia.
An anti-emetic can be used for patients who experience this discomfort.
Physiological Dependency after Prolonged Administration.
Prolonged administration of benzodiazepines and/or opioids to children may induce physiological
dependence.
Sudden discontinuation of these medications may lead to withdrawal.
Symptoms of withdrawal include agitation, anxiety, muscle tension, sleeping for less
than one hour, diarrhea, fever, sweating, tachypnea, and poor feeding.
As mentioned earlier, methadone and lorazepam administration can be given to treat withdrawal
symptoms.
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