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. Please help us improve the content by providing
us with some feedback.

Leave a Reply

Your email address will not be published. Required fields are marked *