painting for preschoolers
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Marks and Sachar: Undertreatment of medical
in-patients with narcotic analgesics.Ann. Int.
Med. 78:173-81.1973
73% of hospitalized patients showed
inadequate pain relief.
GOAL: Minimal effective analgesicconcentration.
(MEAC)
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Why ppl dont get adequate pain
relief:
Underestimated dosing range Overestimated duration of action
Exaggerated respiratory depression
Exaggerated addictions
Opioid concentrations exceed MEAC
only 35% of the time during any 4-hour
dosing intervalWHY?
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History
1968 Sechzar 1971 Keeri-Szanto
1976 Evans
1979 Tamsen
1982 Bennett
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PCA Defined
Any analgesic given by any route ofadministration; on immediate patient
demand in plentiful quantities
PCA pump-fail safe mechanism (so pt doesnt overdose)
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Routes of Administration
Epidural Subcutaneous
IV
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Modes of Administration
Demand dosing When pt feels pain they hit button and they get
opioid IV
Infusion-based systems Constant rate infusion + demand dosing
Get low background amount of opioid but if they
have breakthru (more) pain they can get moreopioid by hitting button
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PCA Terminology
Bolus (Loading Dose)
The cumulative amount of opioid used to initially make thepatient analgesic.
Demand Dose (PCA Dose)
Quantity of analgesic given to the patient by self-administration on the perception of need for additional
analgesia.
Delay Time (Lockout Interval)
The time interval during which the patient cannot initiateanother dose.
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PCA Terminology
Limit (1hr/4hr) Basal Rate (Background Infusion
Rate)
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Limit (1hr/4hr)
The maximum amount of medicationa patient can receive during a 1hr/4hr
time period.
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Basal Rate (Background Infusion
Rate)
The amount of medication infused/hour continuously by the PCA unit.
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The Ideal PCA Drug
Rapid onset Highly efficacious
Intermediate duration of action
Minimal tolerance & side effects
Ex. Morphine, dilatin, phentenol, demerol, etc.
*Cant discharge pt on PCA pump, you must get them off of it first withorals then discharge them
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Adult PCA Morphine
Recommendations
Bolus: 1-4mg Demand Dose: .5-2.5mg
Delay time: 6-12 minutes
4hr Limit: up to 35mg Basal Rate: 0-2mg/hr
Dont memorize doses
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Adult PCA Demerol
Recommendations
Bolus: 10-25mg Demand Dose: 5-20mg
Delay Time: 6-12 minutes
4hr Limit: up to 300mg Basal Rate: 5-20mg/hr
Dont memorize doses
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Patient Education
Explain the device Do not expect complete pain relief
Use as soon as you feel pain (nip it in butt)
Use the device prophylactically Minimize while awake; maximize prior to sleep
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Safety
Drug-related
There is no greater incidence of opioid-related side effects using PCA
vs. other routes of administration.
Mechanical-related
Mechanical-related problems are rare. Siphoningis the major
mechanical problem.
Morphine leaking and getting pts own infusion rate
Can lead to overdose
In 1987, the incidence of siphoning was 1.45 per 100,000.
User-related
The majority of PCA problems are user-related. No device is tamper-
proof.
Thus far, I hve found only one fatality associated with the use of PCA
(JAMA; 1988)
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Advantages of PCA
Rapid onset of analgesia Predictable clinical response
Less demand on nursing staff
Quicker discharge But make sure they are converted to
orals for pain not PCA since you cannot
discharge pts on PCA
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In Conclusion
Safe Cost-effective
Patient Compliant
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What Is It? IntraVenous
Regional
Anesthesia
LOCAL ANESTHETICS:
IVRA
1908 August Bier
AKA: Bier Block
Lost popularity untilthe 60s
Used in UE & LE
surgery
CLINICAL CORRELATIONSLECTURE
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IVRA
ADVANTAGES
Simple
Reliable
Rapid Return To Function Cost Effective
CONCERNS
Duration Of Surgery
Tourniquet Time
(dont put on fibular head b/
c compress common fibular
N)
LA (local anesthetic)
Toxicity
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Technique
Locals utilized include:
Lidocaine (most common, but shortest acting
drug)
Short procedure: using lidocaine okay. .3, .5,1cc etc.Dilute lidocaine with sterile saline helps.
Bupivacaine
Risk of cardiac arrest
Ropivacaine
Derivative of bupivacaine
Less chance of cardiac arrest/depression
Prilocaine
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Technique
IV contralateral limb
Butterfly in injured limb; in foot for venous access
Prepare LA (local anesthetic)
Two tourniquets applied distal to fibular head
Exsanguinate the limb
Inflate proximal tourniquet
Inject LA through your access
If tourniquet pain, inflate distal TQ, then release proximalTQ
How long?
If short procedure, then LA may not have bound to enough tissueand lead to cardiac depression, etc.
If too long, damage from TQ and pain. Perhaps compartmentsyndrome
Adj t T IVRA
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Adjuncts To IVRA
Opiods
Muscle Relaxants
NSAIDs
Clonidine
Potassium
Alkalizing Agents
Opiods and mm. relaxants are the more commonly utilized,and have been the more studied
Opiods include morphine, fentanyl, meperidine, andsufentanil
Muscle relaxants include pancuronium, atracurium,
mivacurium , and cisatracurium
Use adjuncts so you can use less local (leads away from toxicity
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Some Conclusions
Which LA is best?
Are adjuncts useful?
WHICH LA IS BEST?How quicly to they lose sensation
Lido, bupiv, prilo equal to onsetWhen do they get sensation back? Longer acting anesthetics lead to longer
time before sensing backLidocain and robivucaine are equal in preventing TQ pain
Post-op anelgesis in PACU: Longer acting anesthetic. Robivicaine (longer
acting)ARE ADJUNCTS USEFUL?
Dont need as much LA, but may take longer to get anelgesia before starting
procedure.LA by itself does job. No necessarily need other adjuncts.
ROPIVICAINE IS BEST OF ALL LA.
Fi ll S C li ti
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Finally, Some Complications
Seizures
Cardiac Arrest & Death
Incomplete Anesthesia Injection Pain
Tourniquet Pain
-(60MIN is magic number, most LA bound to tissue and lesspain)
Compartment Syndrome
Neuro Damage
Dysphoria, Dizziness, Facial Tingling
Mistakenly Deflating Cuff
Injecting Wrong Drug