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Analgesia Quiz By Clare Di Bona Paracetamol dose should be reduced in which circumstances 1. 2. 3. Paracetamol dose is usually 1g 6hrly oral or IV It should be reduced to 500mg 4hrly in: Elderly Significant liver dysfunction Cachexia/low body weight (<45kg) Severe alcoholism High doses of paracetamol can increase the INR of patients on warfarin TRUE or FALSE? TRUE Monitor INR closely when using regular Warfarin and high doses of paracetamol (>9.1g/week) as INR can increase NSAIDs should always be prescribed routinely for simple analgesic requirements TRUE or FALSE FALSE Not to be used as routine background analgesics Use only in selected patients with good indications (bone pain, inflammation, somatic pain with poor response to other analgesics). Should be prescribed with a time limit List four categories of NSAID side effects and the nature of the side effects. 1. 2. 3. 4. Non-selective NSAIDs inhibit cox-1 and cox-2 Selective NSAIDs inhibit cox-1 GIT: by inhibiting cox-1 (non-selective) the prostaglandins responsible for gastric mucosal protection are also inhibited. This puts patients at risk of gastric ulcers and/or bleeding Platelet: by inhibiting cox-1 (non-selective) this interferes with platelet function by inhibiting platelet aggregation Cardiovascular: increased risk of cardiovascular events ie MI and stroke for both selective and non-selective. In post-MI patients, NSAIDs increase the risk of death and recurrent MI for at least 5 yrs after MI Renal: Pre-existing renal impairement increases the risk of NSAID-induced impairement for both non-selective and selective NSAIDs. It is reasonable in severe pain to use an opioid as a first line analgesic TRUE or FALSE TRUE Certain conditions are known to be very painful ie renal colic and it may be reasonable to use opioid as a first line choice Simple drugs such as paracetamol should be promptly added as these drugs have been shown to be opioid sparing and may improve the effectiveness of the opioid It is reasonable to write two PRN options for oral opioid on the back of the medication chart TRUE or FALSE FALSE You can only ever prescribe one opioid by one route as a PRN option Combining opioids leads to additive side effects such as respiratory depression and sedation which can be fatal for some patients It is reasonable to have tramadol plus an opioid as PRN Name 5 opioid side effects 1. 2. 3. 4. 5. Opioid Side Effects Which is a better determinant of opioid dose age or weight? The best predictor of dosage is pain severity and age The preferred PRN opioid for severe pain is oxycodone IR <40yrs 40-70yrs Oxycodone IR 10-20mg 2hrly oral PRN Oxycodone IR 5-10mg 2hrly oral PRN >70yrs Oxycodone 2.5-5mg 2hrly oral PRN IV opioids should only be used with EXTREME caution in the elderly Give four opioid safety tips 1. 2. 3. 4. Opioid Safety Tips If you are unsure about a drug dose/route/frequency please ask first! Sedation is the first marker of opioid over use (sedation score goes down before respiratory rate) Be especially careful in elderly, children, obese, those with respiratory disease (OSA, COPD) and renal impairement Be aware of mixing sedatives especially benzodiazepines with opioids or mixing different types of opioids Tramadol, tapentadol and gabapentin can accumulate in renal impairement JHC policy that all people receiving up to 2hrly PRN opioids are reviewed routinely by nurses 1hr following the dose At JHC the most common prescribing error is… A) Giving the drug to the wrong patient B) Giving the wrong drug C) Prescribing a drug the patient is allergic to D) Writing the wrong frequency for a drug The most common medication error is prescribing a drug the patient is allergic to. In regards to Migraine, give three nonpharmacological options for treatment 1) 2) 3) 1) avoidance of triggers: sleep deprivation, stress, bright lights, exercise, alcohol 2) environmental modification: sleep in a quiet dark room 3) well hydrated In regards to pharmacological management of migraine give four categories/groups of drugs with an example for each 1. 2. 3. 4. Migraine pharmacological treatment 1. Simple analgesia 1) Aspirin soluble 600-900mg repeat in 4hrs if required OR 2) Diclofenac 50-100mg repeat in 6hrs if required OR 3) Ibuprofen 400mg repeat in 6hrs if required OR 4) Naproxen 550mg repeat in 6hrs if required OR 5) Paracetamol soluble 1g 4hrly max dose 4g daily 2. Anti-emetic combined with IVH Stemetil 12.5-25mg in 1L over 1hr or Largactil 25mg In 1L over 1hr 3. Oral opioid+/- tramadol Oxynorm 5mg 4hrly oral PRN +/- Tramadol 50-100mg 6hrly oral/IV PRN 4. Triptan are not recommended in hospital due to high recurrence of rebound headache Sumatriptan 50-100mg ORAL (300max 24hrs) or intranasal 10-20mg (max 40mg in 24hrs) Bob is 60yrs old he has severe loin pain. He tells you its probable his kidney stones. Give four DDX 1) 2) 3) 4) DDx for Renal Colic The nurse passes you the medication chart asking for an intravenous opioid what will you write up? Titrating IV opioids Morphine 5-20mg titrated using 1mg bolus every 5 minutes OR Fentanyl 100-200mcg titrated using 20mcg bolus every 5 minutes Titrated to effect Stopped if sedation or respiratory depression occur IV route to be used with extreme caution in elderly as side effects less well tolerated Doctor, please explain to me why some doctors use fentanyl and why others use morphine Name 1 difference Name 1 similarity Fentanyl IV versus Morphine IV Fentanyl is metabolised in the liver and suitable for patients with renal failure. Morphine is excreted renally and can accumulate in renal impairement Fentanyl is shorter acting duration of action 0.5-2hrs versus morphine 4-6hrs The adverse effects are similar to morphine but a slightly lower incidence of confusion and constipation You have recommended Tamsulosin 400mcg daily for 2 weeks on discharge. Bob asks you how does this medication work? How does Tamsulosin work? Blocks a1 receptors relaxing smooth muscle in the bladder neck and prostate, decreasing resistance to urinary flow. Evidence that tamsulosin is superior in comparative to other smooth muscle relaxants in terms of increased stone expulsion and a reduction in analgesia requirements, surgical interventions, duration of hospital stay and days off work List four non-pharmacological treatment options for musculoskeletal back pain 1. 2. 3. 4. Non-pharmacological options for back pain • Stay active: resting in bed will increase muscle stiffness. Staying active has been shown to increase the rate of recovery and decrease the time spent off work • Explanation and reassurance: Dispell myth that moving around when there is pain is dangerous. Dispell myth that analgesia will get rid of all the pain. Explain that most cases of back pain will resolve in 4-6 weeks. Focus on positive attitude • Work participation: early re-integration into the workplace plays an important role in recovery • Gentle exercises to strengthen spinal stabilising muscle is important. An outpatient physio follow-up should be arranged by the patient • Thermal therapies such as heat or cold may be transiently useful • Acupuncture may provide a small benefit in pain management In regards to musculoskeletal back pain; true or false? Patients should expect to have no pain in hospital after appropriate analgesia Patients should expect to have some kind of routine imaging of their back pain in hospital Red flags such as fever, loss of weight, trauma indicate possible serious cause of back pain other than musculoskeletal pain Oxynorm and diazepam are ideal medications for discharge Early re-integration into the workplace is important for recovery In regards to musculoskeletal back pain; true or false? Patients should expect to have some kind of routine imaging of their back pain in hospital FALSE Red flags such as fever, loss of weight, trauma indicate possible serious cause of back pain other than musculoskeletal pain TRUE Oxynorm and diazepam are ideal medications for discharge FALSE Early re-integration into the workplace is important for recovery TRUE Doctor I need an MRI for my back pain. How will you respond to this? Responding to requests for imaging in back pain • X-rays are rarely useful when there has been no history of significant trauma however they are a simple test that is often considered • CT scans are not routinely recommended as there is a high prevalence of disc abnormalities on CT in patients without back pain. • MRI is urgently needed only when there is symptoms/signs for spinal canal compression; saddle anaesthesia, poor anal tone, bladder incontinence/retention • CT can be considered in the context of neurological symptoms; unilateral numbness or weakness and discuss with senior regarding inpatient or outpatient In regards to suspected acute coronary syndrome; true or false? Prompt control of chest pain to minimal pain is an important treatment goal in non-ST elevation acute coronary syndrome 02 is no longer routinely used for chest pain unless the 02 sats are <94% GTN should always be given for patients with chest pain If pain does not quickly respond to aspirin or GTN then IV morphine should In regards to suspected acute coronary syndrome; true or false? Prompt control of chest pain to minimal pain is an important treatment goal in non-ST elevation acute coronary syndrome FALSE the target is 0/10 02 is no longer routinely used for chest pain unless the 02 sats are <94% TRUE GTN should always be given for patients with chest pain FALSE (contraindicated if had Viagra last 24hrs or hypotensive) If pain does not quickly respond to aspirin or GTN then IV morphine should TRUE
