Analgesia, Anesthesia, and Sedation Tintinalli Chap 36, 37, 38, 39 - PowerPoint PPT Presentation

Analgesia anesthesia and sedation tintinalli chap 36 37 38 39
Download
1 / 70

  • 153 Views
  • Uploaded on
  • Presentation posted in: General

Analgesia, Anesthesia, and Sedation Tintinalli Chap 36, 37, 38, 39. Nicholas Cardinal, DO. Acute Pain. Accompanies 50-60% of ED patient visits in U.S. and Great Britain Pain The physiologic response to a noxious stimulus Accentuated by fear and anxiety Affected by many factors

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.

Download Presentation

Analgesia, Anesthesia, and Sedation Tintinalli Chap 36, 37, 38, 39

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Analgesia anesthesia and sedation tintinalli chap 36 37 38 39

Analgesia, Anesthesia, and SedationTintinalli Chap 36, 37, 38, 39

Nicholas Cardinal, DO


Acute pain

Acute Pain

  • Accompanies 50-60% of ED patient visits in U.S. and Great Britain

  • Pain

    • The physiologic response to a noxious stimulus

    • Accentuated by fear and anxiety

    • Affected by many factors

      • Medical Condition

      • Physical and Emotional Maturity

      • Cognitive State

      • Meaning of Pain

      • Family Attitudes, Culture, and Environment


Peripheral nervous system

Peripheral Nervous System

  • Responsible for somatic pain

  • Registers the original noxious stimulus and conducts it to the CNS

  • Components

    • Primary Afferent Peripheral Nociceptors

    • Dorsal Horn of the Spinal Cord

    • Supraspinal Centers


Pain receptors

Pain Receptors

  • µ1 receptor

    • Stimulation produces supraspinal analgesia, euphoria, miosis, and urinary retention

  • µ2 receptor

    • Stimulation responsible for respiratory depression, gastrointestinal slowing, and cardiovascular slowing

    • Likely source of addiction

  • Κ receptor

    • Stimulation produces dysphoria and spinal-level analgesia


Evaluation

Evaluation

  • Assessment of Pain

    • Non-self-report Measurement

    • Self-report Measurement

      • Adjective Rating Scale

      • Visual Analog Scale

      • Numerical Rating Scale

      • Five-point Global Scale

      • Verbal Quantitative Scale

      • Global Satisfaction Question


Non self report measurement

Non-self-report Measurement

  • More useful as confirmatory tool than as primary assessment tool

    • Physiologic parameter variation

      • Respiratory

      • Cardiovascular

    • Changes in expression and movement


Self report measurement

Self-report Measurement

  • Mainstay of pain assessment

  • Needs to be applied at onset of intervention and then re-evaluated frequently

  • Value assigned by patient should be used as a reference point on which to base pain control


Unique patient populations

Unique Patient Populations

  • Difficulty communicating places patients at risk for inadequate pain management

    • Cognitively impaired

    • Psychotic

    • Extremely young or old

    • Language Barriers

    • Extreme cultural or educational disparity


Modalities of pain management

Modalities of Pain Management

  • Pharmacologic

  • Nonpharmacologic

  • Cognitive-behavioral

  • Physical techniques


Pharmacologic modalities

Pharmacologic Modalities

  • Opioids

  • NSAIDs

  • Acetaminophen

  • Adjuncts

    • Anxiolytics

    • Antiemetics


Severity of pain

Severity of Pain

  • Mild

    • NSAIDs

  • Moderate to Severe

    • Systemic opioids and/or NSAIDs

    • Local or Regional Neural Blockade


Opioid agonists

Opioid Agonists


Relative potency estimates

Relative Potency Estimates

  • Basis for selecting appropriate starting dose, changing route of administration, or switching to another opioid


Meperidine

Meperidine

  • Once the mainstay of pain management in EDs

  • Should no longer be used for acute pain management

  • Is the lowest potency opioid and is often underdosed

  • Metabolite has been shown to cause CNS toxicity in patients with compromised renal function or who are taking MAOIs

  • Metabolite can produce prolonged states of sedation of up to 48 hours

  • Reported to produce more euphoria and may have an increased risk of addiction


Codeine

Codeine

  • Standard dose produces little analgesic effect above that of acetaminophen or NSAIDs

  • Produces more nausea, vomiting, and dysphoria


Adverse effects of opioids

Adverse Effects of Opioids

  • N/V

  • Constipation

  • Pruritus

  • Urinary retention

  • Confusion

  • Respiratory Depression


Analgesic adjuncts

Analgesic Adjuncts

  • May provide pain relief at lower opiate dose

    • Anxiolytics

      • Not recommended

      • Synergy with opiates can produce additive adverse effects

    • Antiemetics

      • May potentiate opiates


Nonopioid agents

Nonopioid Agents

Acetaminophen

NSAIDs

Analgesic and anti-inflammatory

Have significant opioid dose-sparing effects

Adverse effects include platelet dysfunction, impaired coagulation, and gastrointestinal irritation and bleeding

Acute Renal Failure in elderly, volume depleted

  • Mild to moderate pain

  • Is not an anti-inflammatory and does not affect platelet aggregation

  • No change required for renal or mild hepatic impairment


Nonopoid agents

Nonopoid Agents

Corticosteroids

Other Agents

Ketamine

Nitrous Oxide

Tricyclic Antidepressants

Anticonvulsants

  • Potent inhibitors of inflammation

  • Used for visceral, orthopedic, and neuropathic pain

  • Short-term d/t adverse effects


Ketamine

Ketamine

  • “Dissociative” anesthetic

  • Causes minimal respiratory depression

  • Good for brief minor procedures

  • Adverse effects include elevated ICP, elevated intraocular pressure, hypersalivation, and reemergence phenomena

  • Avoid in closed head injury or suspected elevated ICP


Nitrous oxide

Nitrous Oxide

  • Fast onset, short acting

  • Sedative analgesic

  • Inhalational

  • Useful in wound dressing and brief, minor procedures

  • Contraindications include altered mental status, head injury, suspected pneumothorax, and perforated abdominal viscus


Basic dosing guidelines

Basic Dosing Guidelines

  • Titrate dose toward desired effect while minimizing unwanted effects

  • Decrease initial dosing in setting of comorbidity

    • Altered mental status

    • Hemodynamic instability

    • Respiratory dysfunction

    • Multisystem trauma


Elderly

Elderly

  • May have more than one source of pain

  • Comorbidities

  • At increased risk for drug-drug interaction

  • More sensitive to analgesic effects, sedation, respiratory depression, and cognitive and neuropsychiatric dysfunction


Dosing adjustments

Dosing Adjustments

  • Renal and Hepatic Dysfunction

  • Respiratory Insufficiency

    • COPD

    • Cystic fibrosis

    • Neuromuscular Disorders

      • Muscular Dystrophy

      • Myasthenia Gravis

  • Drug Interactions

    • Anxiolytics

      • Synergistic sedative effects

    • Monoamine Oxidase Inhibitors

      • Fatal reactions with meperidine

    • Tricyclic Antidepressants

      • May increase morphine levels


  • Nonpharmacologic modalities

    Nonpharmacologic Modalities

    • Heat/cold application

    • Immobilization and elevation of injured extremities

    • Cognitive-Behavioral techniqes

    • Transcutaneous Electrical Nerve Stimulation

    • Acupuncture


    Pain management in trauma

    Pain Management in Trauma

    • Closed Head Injury

      • Must allow for continuous monitoring of neurovascular status

      • Maximal use of regional and nonpharmacologic modalities

    • Minor Trauma

      • NSAID use remains controversial d/t bleeding risk and acute renal failure in the volume depleted patient

    • Limb Injury

      • Continuous monitoring of neurovascular status


    Local anesthesia

    Local Anesthesia

    • Cocaine

      • First isolated in Europe between 1859-1860

      • Toxic and addictive effects were rapidly noticed resulting in patient deaths and addicted medical staff

    • Ester Local Anesthetics

      • Tropocaine

      • Eucaine

      • Benzocaine

      • Procaine

      • Tetracaine

  • Amide Local Anesthetics

    • Lidocaine

    • Mepivacaine

    • Prilocaine

    • Bupivacaine


  • Local anesthetic agents

    Local Anesthetic Agents

    • Synthetic drugs derived from cocaine

    • Weak bases supplied in an acidic solution

    • Anesthetic action produced by drug molecules interrupting and temporarily stopping conduction


    Epinephrine

    Epinephrine

    • Acts through vasoconstriction

    • Avoided in end-arterial field

    • Advantages

      • Provides longer duration of anesthesia

      • Promotes wound hemostasis

      • Slows systemic absorption

      • Decreases potential for toxicity

      • Allows greater volume to be used for extensive laceration repair


    Toxicity of local anesthetics

    Toxicity of Local Anesthetics

    • Related to potency and duration of action

    • Serious adverse reactions more common in amides than the esters

    • Enhanced by hypercarbia, hypoxemia, and acidosis

    • Usually due to inadvertent IV injection or excessive dose


    Cns toxicity

    CNS Toxicity

    • Due to conduction block

    • Directly related to lipid solubility

    • Symptoms range from perioral tingling and numbness to confusion, seizure and coma

    • Seizure activity is a warning for impending ventricular arrhythmias and cardiovascular collapse


    Cardiovascular toxicity

    Cardiovascular Toxicity

    • Dose-dependent

    • Mediate through sodium channel blockade within the heart

    • Worsened by pregnancy

    • Effects include myocardial depression and ventricular dysrhythmias

    • Bupivacaine has highest incidence and is contraindicated for use in regional anesthesia


    Methemoglobinemia

    Methemoglobinemia

    • Prilocaine and benzocaine cause oxidation of ferric form of hemoglobin to ferrous form

    • Visible cyanosis results when concentration exceeds 1.5 g/dL

    • Usually benign


    Amide local anesthetics

    Amide Local Anesthetics

    • Lidocaine

      • Most commonly used anesthetic in the ED

      • Excellent efficacy and low toxicity profile

      • Rapid onset and intermediate duration of action

    • Prilocaine

      • Low CV toxicity profile

      • May cause methemoglobinemia after large IV bolus

      • Used with lidocaine in EMLA cream

    • Bupivacaine

      • Slow onset and long duration of action

      • High CV toxicity potential

      • Use in prolonged procedures or when longer postprocedural anesthesia is required

    • Mepivacaine

      • Rapid onset and intermediate duration of action

      • Intermediate toxicity


    Ester local anesthetics

    Ester Local Anesthetics

    • Procaine

      • Slow onset

      • Short acting

      • Very short half-life

    • Tetracaine

      • Slow onset

      • Long duration of action

      • Injectable for spinal anesthesia

      • Topical for use on eye, mucous membranes, and skin


    Alternative agents

    Alternative Agents

    • Diphenhydramine

      • Effective local anesthetic

      • Injection more painful than lidocaine

      • Can cause tissue irritation and skin necrosis

    • Benzyl Alcohol

      • As effective as lidocaine

      • Short duration usually requiring additional injections during procedure


    Local anesthetic infiltration

    Local Anesthetic Infiltration

    • Most common use of local anesthetics in ED

    • Rapid onset

    • Low risk of systemic toxicity

    • Used for wound repair and invasive procedures

    • Lidocaine for short procedures and bupivacainefor longer procedures


    Minimizing pain of infiltration

    Minimizing Pain of Infiltration

    • 27- or 30-gauge needle

    • Deep, slow infiltration

    • Buffered lidocaine

      • Sodium bicarbonate reduces pain

    • Warm lidocaine

      • 37-42 degrees C

    • Injection through wound margins

    • Distraction techniques


    Topical anesthetics

    Topical Anesthetics

    • Used to reduce discomfort of local procedures

    • Work better on head and neck than extremities

    • Advantages

      • Painless

      • Do not distort wound edges

      • May provide good hemostasis if formulation includes a vasoconstrictive agent


    Topical anesthetics1

    Topical Anesthetics

    • TAC

      • 0.5% Tetracaine, 0.05% Adrenaline, 11.8% Cocaine

      • Other mixtures are cheaper, have less toxicity, and do not contain a controlled substance

    • LET

      • 4% Lidocaine, 0.1% Epinephrine, 0.5% Tetracaine

      • Prepared in single-use 5-ml vials

      • Applied directly to wound for 20-30 minutes

      • Avoid contact with mucous membranes, fingers/toes, ear pinna, penis, and tip of nose


    Topical anesthetics2

    Topical Anesthetics

    • EMLA

      • Eutectic Mixture of Local Anesthetics (2.5% Lidocaine and 2.5% Prilocaine)

      • Available preparation is nonsterile and should only be applied to intact skin

      • Applied directly to skin and covered with occlusive dressing

      • Analgesia at 1 hour, peak at 2 hours

    • Lidocaine

      • Available in solution, ointment, cream and jelly preparations

      • Commonly used to facilitate placement of urinary catheters, nasogastric tubes, and fiberoptic scopes


    Other topical anesthetic agents

    Other Topical Anesthetic Agents

    • Benzocaine

      • Used for mucosal anesthesia to relieve pain from oral ulcers, wounds, inflammation and to facilitate passage of nasogastric tubes or endoscopy

    • Iontophoresis

      • Delivery of topical anesthetic with mild electrical current

    • Ethyl Chloride

      • Skin refrigerant or vapocoolant delivered by a spray

      • Causes anesthesia for 30-60 seconds

      • Not for use on mucosal surfaces


    Regional anesthetic procedures

    Regional Anesthetic Procedures

    • Can minimize opiate use

    • Decreases need for procedural sedation

    • Should be administered in lowest dosage that results in an effective block

    • Epinephrine can be added to enhance duration, efficacy, reliability, and safety


    Peripheral nerve blocks

    Peripheral Nerve Blocks

    • Advantageous for procedures on the digits, hand, and foot

    • Require less total anesthetic

    • Often less painful than local infiltration

    • Onset of anesthesia may be up to 15 minutes

    • Document neurovascular status prior to block

    • Complications include nerve injury and systemic toxicity


    Wrist blocks

    Wrist Blocks

    • Used for lacerations of the hand

    • Median Nerve

    • Ulnar Nerve

    • Radial Nerve


    Digital nerve block

    Digital Nerve Block

    • More rapid onset than metacarpal block

    • Used for laceration repair, I&D of paronychia, or finger/toenail removal

    • Large volumes of anesthetic can result in compartment syndrome


    Foot blocks

    Foot Blocks

    • Anesthesia for surgical procedures of the foot

    • Sensation to foot supplied by 5 different nerves

      • Posterior Tibial Nerve

      • Sural Nerve

      • Saphenous Nerve

      • Superficial Peroneal Nerve

      • Deep Peroneal Nerve

  • Most blocks involve at least 2 nerves

  • Contraindications include peripheral vascular disease and traumatic circulatory compromise


  • Facial and oral blocks

    Facial and Oral Blocks

    • Anesthesia to commonly injured areas

      • Forehead, chin, lips, nose, tongue, ear

  • Often require blockade of more than one nerve

  • Topical EMLA cream or refrigerant sprays should be applied prior to injection

  • 2% lidocaine can be applied to oral mucosa

  • Avoid direct infiltration of pinna d/t risk of tissue necrosis


  • Femoral nerve block

    Femoral Nerve Block

    • Effective for relieving pain of femoral neck fracture

    • Useful in multiple trauma patient


    Intercostal block

    Intercostal Block

    • Management of pain following chest trauma or from a chest tube

    • Contraindications include local soft tissue disease and contralateralpneumothorax

    • High systemic absorption and toxicity


    Hematoma blocks

    Hematoma Blocks

    • Simple, quick, and effective for closed fracture reduction

    • Not as efficacious as IV Regional (Bier’s) Block


    Intravenous regional block bier s

    Intravenous Regional Block (Bier’s)

    • IV infusion of local anesthetic distal to an inflated pneumatic tourniquet

    • Used for fracture reductions, large laceration repair, and foreign body removal

    • Most commonly used for upper extremity procedures

    • Duration is 30-60 minutes

    • Requires continuous monitoring and patient NPO for 4 hours

    • Contraindications include peripheral vascular disease, raynaud syndrome, sickle cell disease, cardiac conduction abnormalities, hypertension, cellulitis, and children under 5


    Levels of sedation

    Levels of Sedation

    • Minimal Sedation

      • drug-induced anxiolysis

      • Patient responds normally to verbal commands

      • Cognitive function and coordination may be impaired

      • Ventilatory and cardiovascular function is unaffected

    • Moderate Sedation and Analgesia

      • PSA or “conscious sedation”

      • Drug-induce depression of consciousness

      • Patient responds purposefully to verbal commands alone or with light tactile stimulation

    • Deep Sedation and Analgesia

      • Patient cannot be easily aroused but responds purposefully after repeated or painful stimulation

      • May require assistance in maintaining patent airway and spontaneous ventilation may be inadequate

    • Anesthesia

      • Drug-induced loss of consciousness

      • Patient cannot be aroused even with painful stimulation

      • Requires assistance in maintaining a patent airway and may need positive pressure ventilation

      • Cardiovascular function may be impaired


    Procedural sedation and analgesia

    Procedural Sedation and Analgesia

    • Indications

      • Treatment of severe pain

      • Attenuation of pain and anxiety associated with procedures

      • Rapid tranquilization

      • Need to perform a diagnostic procedure

    • Agents

      • Often have narrow therapeutic index

      • Should be given in small incremental doses

    • Monitoring

      • Should be performed by another provider who understands the pharmacology, possesses sound airway-management skills, and will not be distracted by other tasks


    Patient assessment

    Patient Assessment

    • Classification

      • I

        • Normal healthy patient

      • II

        • Mild systemic disease

          • Asthma

          • Controlled diabetes

      • III

        • Moderate systemic disease

          • Stable angina

          • Diabetes with hyperglycemia

          • Moderate COPD

    • IV

      • Severe systemic disease

        • Unstable angina

        • DKA

    • V

      • Moribund

    • +E

      • All ED patients


    Agents in psa

    Agents in PSA

    • Opioids

      • Morphine

      • Fentanyl

  • Anxiolytics

    • Midazolam

  • Anesthetic Agents

    • Propofol

    • Etomidate

    • Ketamine

    • Methohexital


  • Midazolam

    Midazolam

    • Benzodiazepine

      • potentiate inhibitory activity of GABA in CNS

      • Result in sedation, amnesia, anxiolysis, respiratory depression, and anticonvulsant effects

    • Use cautiously in combination with alcohol or opioids d/t increased sedative and respiratory-depressant effects


    Antidotal agents

    Antidotal Agents

    • Naloxone

      • Competitive opioid antagonist at µ receptors

      • Indicated for reversal of unwanted respiratory depression after opioid administration

      • May not reverse fentanyl-induced chest wall rigidity

      • Patients who are opioid dependent may develop withdrawal with large doses

    • Flumazenil

      • Competitive antagonist of benzodiazepines

      • Use with caution in benzodiazepine-dependent patients

      • Indicated for reversal of respiratory depression caused by benzodiazepines


    Chronic pain

    Chronic Pain

    • Painful condition lasting longer than 3 months, persists beyond the reasonable time for an injury to heal, or persists 1 month beyond the usual course of an acute disease

    • 4 Types

      • Pain persisting beyond the normal heal time for a disease or injury

      • Pain related to a chronic degenerative disease or persistent neurologic condition

      • Cancer-related pain

      • Pain that emerges or persists without an identifiable cause


    Chronic pain1

    Chronic Pain

    • Affects approximately 1/3 of U.S. population at least once during an individual’s lifetime

    • Estimate annual cost of 80-90 billion dollars


    Causes of chronic pain

    Causes of Chronic Pain

    • Chronic pathologic process in the musculoskeletal or vascular system

    • Chronic pathologic process in one of the organ systems

    • Prolonged dysfunction in the peripheral or central nervous system

    • Psychological or environmental disorder


    Pathophysiology

    Pathophysiology

    • 3 Types of Chronic Pain

      • Nociceptive associated with ongoing tissue damage

        • Cancer

        • Chronic pancreatitis

      • Neuropathic pain associated with nervous system dysfunction

        • Complex Regional Pain type II

        • Postherpetic neuralgia

        • Phantom Limb Pain

      • Psychogenic pain

        • No identifiable cause

        • Diagnosis of exclusion


    Associated conditions

    Associated Conditions

    • Myofascial Headache

      • Variant of tension headache

      • Presence of trigger points on the scalp

      • Pain is constant, squeezing, and occasionally shooting

      • Neck pain/stiffness; N/V

    • Transformed Migraine

      • Classic migraine headaches change over time

      • One cause is frequent treatment with opioids

      • Vascular symptoms become predominantly muscular symptoms

      • Pain is nonthrobbing, squeezing, bandlike

      • Antimigraine medications fail to work


    Associated conditions1

    Associated Conditions

    • Fibromyalgia

      • Symptoms persist greater than 3 months

      • Presence of 11 of 18 specific tender points

      • Non-restorative sleep

      • Muscle stiffness

      • Generalized aching pain

    • Chronic Myofascial Chest Pain

      • Dull, constant pain

      • Trigger points on chest wall


    Associated conditions2

    Associated Conditions

    • Back Pain

      • Types

        • Myofascial

          • Constant, dull, and occasionally shooting pain

          • Does not follow classic nerve distribution

          • May be exacerbated by movement

          • Usually have trigger points at site of greatest pain

          • No muscle atrophy or weakness

        • Articular

          • Constant, sharp pain

          • Exacerbated by movement

          • Associated with local muscle spasm

        • Neurogenic

          • Burning, shooting, or aching pain

          • Constant or intermittent

          • Usually more severe in the leg than the back

          • Follows a dermatome

          • May have muscle atrophy and reflex changes


    Associated conditions3

    Associated Conditions

    • Complex Regional Pain

      • Symptoms

        • Allodynia

        • Persistant burning or shooting pain

      • Type I (Reflex Sympathetic Dystrophy)

        • d/t prolonged immobilization or disuse

      • Type II (Causalgia)

        • d/t peripheral nerve injury


    Associated conditions4

    Associated Conditions

    • Postherpetic Neuralgia

      • Follows course of an acute episode of herpes zoster in 8-70% of cases

      • Increased incidence with advancing age

      • Symptoms include allodynia, shooting and lancinating pain, hyperesthesia in involved dermatome

    • Phantom Limb Pain

      • More frequent in patients who had pain in the extremity prior to amputation

      • Aching, cramping, burning, tearing, or squeezing pain

      • Often does not respond to any treatment


    Treatment of chronic pain

    Treatment of Chronic Pain

    • Opioids

      • Should only be used if they enhance function at home and at work

      • One physician should be the sole prescriber

    • NSAIDs

      • More helpful in acute than in chronic pain

    • Antidepressants

      • Amitriptyline


    Treatment of chronic pain1

    Treatment of Chronic Pain

    • Anticonvulsants

      • Useful for neuropathic pain

        • Carbamazepine

        • Clonazepam

        • Gabapentin

    • Other Agents

      • Calcitonin

      • Prednisone

      • Muscle Relaxants

      • Tramadol


    Chronic pain in the elderly

    Chronic Pain in the Elderly

    • Doses should be reduced to avoid side effects

      • NSAIDs

        • GI bleeding

        • Renal disease

      • Opioids

        • Debilitating sedation

        • Constipation


  • Login