Pharmacology Session 9:

Analgesics and anesthetics, lots of narcotics, and sedation. These are information packed and there is a lot that is not in the notes so be sure to double check with your own resources. Thanks for reading!

-Peter

Analgesics and Anesthetics

Analgesics – treat pain, w/out loss of consciousness

Anesthetics – block conduction along the axon to stop sensation

  • General – loss of consciousness for surgery
  • Regional – targets nerves, larger body region such as an arm or abdomen.
  • Local – very small region like a hand

Acute pain has an identifiable current issue

Chronic long term, and the cause may not be identifiable

Assess the patient’s eyes(PERRLA), and allergies very close

Narcotic are potentially addictive and scheduled

  • act on CNS

and non narcotic are not addictive

  • act on the peripheral nervous system

Opioid Analgesics

  • resp. depression
  • mu site has resp depression
  • Kappa site has no resp depression
  • delta
  • sigma

Narcotics adverse effects

  • resp rate is 12-20 breaths in a min
    • low is under 8
  • takes effect in about 7 mins IV
  • can develop tolerance
  • constipation
  • hypOtension
  • cannot make legal decisions
  • fall risk
  • Overdose
    • pinpoint pupil
      • from CNS over stimulation
    • Coma
    • Bradypnea
    • Narcan is antidote

analgesic ladder from the WHO

  • non-opioid analgesic
    • NSAIDS
  • mild opioid
    • codeine
  • opioid
    • morphine
  • Morphine
    • narcotic
      • moderate to severe pain
      • can be given through almost all routes
      • cross BBB
      • S/E: resp depression, constipation, nausea, Miosis(pinpoint pupils)
      • morpheus god of sleep
      • give before the pain occurs if possible
      • PCA pump allows for the patient to not fall out of the TPR
        • is better than PRN, or fixed schedule
        • decreases overdoses
        • can use smaller doses
        • empowers patient
      • Tolerance to other opiates
  • Meperadine (demoral)
    • narcotic
      • same action as morphine with a shorter action
      • treats post anesthesia shivers or rigors that can occur
      • no cough suppression effect
  • Fentanyl
    • narcotic
      • one hundred times stronger than morphine
      • Lollipop form in some cases for chronic pain (cancer)
        • will kill a kiddo!
  • Diacetylmorphine (heroin)
  • Methadone
    • narcotic
      • longest duration of action
      • long QT interval
      • for coming off of narcotics and given in clinics
  • Codine
    • Narcotic
      • 1/10th power of morphine
      • 5x power of aspirin, or acetaminophen
  • Hydrocodone (vicodin)
    • analgesic and antitussive
        • moved up to a schedule 2 drug
        • high level of abuse
  • Oxycodone
    • ten times more powerful than codeine
    • extended release is oxycontin
    • schedule 2 as well
  • Hydromorphone (dilaudid)
    • strong opiate
  • nonopiate CNS actinganalgesic
    • Tramadol
      • schedule 4
      • not an opiate but binds to the receptor
  • clonidine
      • alpha 2 Agonist
      • not for patients with opiate dependence
      • NSAID
      • more potent than codeine and less potent than
      • side effects: dizzy, sedation, less resp

non opiate

  • COX inhibitors
    • COX 1: promotes Platelet aggregation, GI protection, renal fxn, (GOOD)
    • COX 2: promote inflammation (bad)
  • NSAID
    • gen 1: inhibit COX one and two
      • inhibit inflammation
      • inhibits prostaglandins in the stomach, so there is a higher chance for ulcers
    • Gen 2:
    • some studies show slowed healing of muscle, bone and ligament injuries.
  • ASA (aspirin)
    • gen 1 NSAID
    • inhibits platelet aggregation until there is a reproduction of more platelets
      • irreversible in the platelets that it affects
    • anti prostaglandin (inflammation)
    • do not use in kiddos
    • s/e: salicylism (ringing in ears points towards OD), reye’s syndrome, Renal impairment
    • Too Much? Tinnitus, respiratory depression, HypERthermia, can cause metabolic acidosis, then resp alkalosis to compensate.
  • Ibuprofen (advil, Motrin)
    • S/E: can cause renal damage, and GI bleeding, Retention of NA and H2O (watch out for HF patients)
  • Ketorolac (toradol)
    • one of the oldest NSAIDS
      • strong! acute up to severe pain
  • COX 2 inhibitors
    • celecoxib
      • similar strength to ibuprofen
      • less stomach ulcers than other NSAIDs (some evidence)
  • acetaminophen (Tylenol)
    • anti-prostaglandin
      • metabolized in liver (watch out for this)
        • 3 g per day is the most dose per day
      • works in CNS
      • low GI
      • irritation
      • can be used with kids
      • s/e: liver damage with ETOH is a high risk,
      • toxicity: 25 grams for adult
        • top cause of acute liver failure
        • the OD patient will die in 3-5 days from the liver damage
  • medical marijuana
    • schedule 1
      • two drugs: Dronabinol, nabilone, sativex
      • for pain, appetite, nausea, glaucoma, seizures
      • preg. risk

Anesthetics

  • General – loss of consciousness for surgery
  • Regional – targets nerves, larger body region such as an arm or abdomen.
  • Local – very small region like a hand
  • preanesthetics will treat the negative effects of anesthesia
  • two classes to allow a lower dose to be used for each
    • inhalation
    • IV
  • stages
    • there are 4
    • 1 is the beginning and 4 is close to death
    • 3 is the stage for operation
  • NM blocker
    • Depolarizing neuromuscular blocker
      • Succinylcholine
        • ultra short acting agent
        • period of mm contractions before flaccid paralysis
        • no CNS effect
        • S/E: prolonged apnea, hyperthermia, mm pain post op,
  • balance is important
    • one analgesic, and one anesthetic
  • Propofol
    • rapid onset and short duration
    • no analgesic effect
    • s/e: resp depression, rhabdo
  • Ketamine (ketalar)
    • dissociative anesthetic
      • abuse potential
      • a lot of s/e so not used as much anymore
  • Local anesthesia
    • -caine
    • fingers, ears,nose, toes, and those
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