Pain: Why treat it?. Humanitarian JCAHO (2001) Blunt autonomic and somatic response to pain - Elevated metabolic rate - Elevated O2 consumption - Hypercoagulability - Altered immune status - Development of chronic pain. Pain: Why Don’t We Treat It Well?. Lack of concern/caring
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Blunt autonomic and somatic response to pain
- Elevated metabolic rate
- Elevated O2 consumption
- Altered immune status
- Development of chronic pain
Dose-dependent blockage of sodium channels in neurons
Amides and esters (amides less allergenic)
Amides:Lidocaine, bupivacaine, prilocaine
Lidocaine dosing: 5 mg/kg without epi
7 mg with epi
Decreased incidence of GI bleeding
Didn’t inhibit platelet aggregation
Initial data on side effects was on usage for greater than 1-2 years
Now some data on side effects as analgesics for CABG patients
* Offset prolonged after long-term use
** Active metabolite accumulation causes excessive narcosis
36 y.o morbidly obese woman with RUQ pain at 20 hrs, RUQ tenderness, WBC 13, US with stones, wall 5.0 mm
What’s she got?
How will we manage her pain? What are our Prospects?
- Cardiac failure, rhabdomyolysis, severe metabolic acidosis, and renal failure
- Caution should be exercised at doses > 80 mcg/kg/min for more than 48 hours
- Particularly problematic when used simultaneously in patient receiving catecholamines and/or steroids
- Evaluate when a patient has unexplained acidosis
- Particularly problematic in alcoholics (due to doses used) and renal failure
Jacobi J, Fraser GL, Coursin D, et al. Crit Care Med. 2002;30:119-141.
- QTc prolongation with ziprasidone IM
- Hypotension with olanzapine IM
- No evidence that one is preferred over another