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Clinical pearls for lecture 10 Local Anesthetics • Medical: most commonly used is 1-2% Lidocaine, most commonly used with 1:100K epinephrine • Addition of epinephrine decreases the redistribut... ion of the LA throughout the body, thus prolonging the effects of the anesthesia • LA with epinephrine is often used as a hemostatic agent, particularly in surgical/trauma settings • Can be given as regional or local anesthesia o Dental: most commonly used is 2% Lidocaine w/ 1:100k epi, utilized as local infiltrations and regional blocks, providing anesthesia for 2-3 hours; many other types of LA are on the market and can be tailored to the patient’s needs, such as Bupivicaine (Marcaine) which causes anesthesia for 8-10 hours o ABSOLUTE CONTRAINDICATIONS to LA use with EPI: TCA’s, MAOIs, cocaine use, MI within 3 months o RELATIVE CONTRAINDICATIONS to LA use with EPI: significant cardiovascular history, MI within 6 months o In light of the recent opioid epidemic, orthopedic surgeons and oral surgeons are utilizing lipid-solubilized Marcaine for regional/local anesthesia, which lasts up to 3-4 days – called Exparel. As the peak inflammation occurs at 48-72 hours following surgery, peak pain is experienced during this time. The use of Exparel and other, long-lasting local anesthetics reduces the need for opioid use following joint/jaw surgeries. Exparel (bupivacaine) is now FDA approved for use throughout the body. Triptans • dose o Don’t use more than 2 pills in a day but wait at least 2 hours before giving second • This can lead to dependence which will result in a worse headache Pills are significantly cheaper than nasal sprays • Nasal sprays are only brand name and pills are mainly generic • Therefore, start with pills if these don’t work then move to nasal sprays Preventative • Personally I have seen propranolol and metoprolol used for prevention purposes, but remember these do lower blood pressure, so make sure that these will not do more harm to patient then prevention of HA • Counsel patient about signs and symptoms of hypotension • Lightheadedness and dizziness Clinical Pearls for lecture 11 Opioids Adverse Effects • Constipation is the biggest complaint I hear about • Make sure to always think “pushy and mushy” • Suggest Colace (stool softener) and docusate (stimulate) ▪ Combo pill -- dulcolax o Nausea and vomiting o Drowsiness is also very common • ▪ Trying to prevent opioid crisis Norco/Percocet (Hydrocodone/APAP, Oxycodone/ APAP) • This has APAP in it!! • Do not allow the patient to take any OTC Tylenol, this can cause them to go above the daily recommended amount • Can suggest they use aleve or advil or other NSAIDS if patient needs to supplement with something Duragesic (Fentanyl) • Most commonly comes in Patches that are used every 3 days • Make sure they remove the old patch before adding a new one • Apply to areas that don’t have a lot of hair, this prevents it from falling off early • Rotate spots every time! • Can be used when taking a shower, should not fall off with water Narcan (naloxone) • Can be prescribed to known drug abuser/friends or family of a drug abuser for prevention of overdose • Walgreens and CVS provide this without a prescription at select locations Ultram (tramadol) • Do not exceed more than 8 tablets a day • Increases the risk of seizure o Claim to fame – doesn’t cause as much drowsiness or upset stomach as the opioids Meds Bran d name Administr ation Morph ine poten cy Advers e effects Pearls sched ule Morphine Avinza IV, PO Standa Hives Accumula II Kadian rd Constipa tion of Oramo tion active rph Respirat metabolit ory es leads depressi to on increased Mental confusion issues , agitation, delirium Oxymorphon Opana PO, IM, IV 3 x Similar SSS- II e strong to above brand er name Hydromorph Dilaudi PO, IV 10 x Similar II one d strong to above Exalgo er Hydrocodone Norco PO similar Similar II /APAP Vicodi to above n Meperidine Demer PO, IM, IV Decrea Avoid Metabolit II ol se MAOI e potenc increase normeper y and duratio n Increas ed toxicity d risk of hyperpyr exia and seizures idine accumula tes in renal leads to CNS irritability Fentanyl Durag esic Abstral Actiq SL, Buccal, Nasal, IV, Transderma l 100 x strong er Respirat ory depressi on Opiate tolerate ONLY! – 60 Morphine equivalen t only II Methadone Dolop hine PO, IV, IM Decrea sed euphor ia Similar analge sia Increas ed duratio n QTc prolonga tion Used for chronic pain controlled withdraw al for heroin addicts II Clinical Pearls of lecture 12 NSAIDS • The best way to prevent GI bleeds is to make sure they take them after a meal • Always have something on the stomach before taking an NSAID o Make sure they are monitoring signs and symptoms of GI bleed (black, tarry stools) o Patients that take both NSAIDS and ACE-inhibitors should be monitored extra closely because they will worsen kidney function • ACE-inhibitors cause efferent renal arteriolar vasoconstriction that increases glomerular filtration pressures. • NSAIDS inhibit prostaglandins and bradykinin, producing vasoconstriction of the afferent renal arteriole and reduce the regular glomerular blood flow of the kidney • Simply stated, ACE-inhibitors cause vasoconstriction of the efferent (exiting) glomerulus arteriole and the NSAIDS cause vasoconstriction of the afferent (entering) arteriole of the glomerulus ▪ Vasoconstriction of afferent arteriole causes less blood flow to the glomerulus; increased vasoconstriction of the efferent arteriole causes an increase in GFR, causing glomerular damage through decreased blood flow and increased pressure in the glomerulus Glucocorticoids • Also very important to eat with glucocorticoids to prevent GI [Show More]

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