Lecture multimodal anesthesia 2017 for spinal surgery
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This document discusses multimodal anesthesia and pain management. It defines pain and discusses endogenous opioids, various opioid drugs like morphine, heroin, oxycodone, and their properties, mechanisms of action, and histories. It also covers opioid withdrawal symptoms and timelines. Non-opioid pain management options like gabapentin, pregabalin, NSAIDs, and neuroaxial blocks are mentioned. Risks of various treatments like respiratory depression, tolerance, and addiction are summarized.
Lecture multimodal anesthesia 2017 for spinal surgery
- 1. Multimodal anesthesia Upper Chesapeake Medical Center Spine Conference Friday July 7th, 2017
- 2. An unpleasant sensation occurring in varying degrees of severity as a consequence of injury, disease, or emotional disorder
- 3. pain • Definition: an internal and personal phenomenon consisting of an unpleasant sensory and emotional experience. This experience is associated with actual or potential tissue damage or described in terms of such damage 3
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- 8. 8 Endogenous morphine Secreted in response to pain, strenous exercise, orgasm or excitement
- 9. Opium poppy fruit latex from cut • Opium poppy fruit exuding latex from a cut • BotanicalOpium • Source plant(s) Papaver somniferum • Part(s) of plant latex • Geographic origin Indochina • Active ingredients Morphine, Codeine • Main producers Afghanistan (primary), Pakistan, Northern India, Thailand, Laos, Myanmar, Mexico, Colombia, Hungary • Main consumers worldwide (#1: U.S.) 9
- 10. opioids 1. Cortex: analgesia, euphoria, sedation, addiction 2. Hypothalamus/Pituatary: decrease testosterone 3. Brainstem: N/V, Mioisis, respiratory depression 4. SC: analgesia 5. GI: gastroparesis, decreased peristalsis 6. UG: increased tone ureter, detrussor, urinary sphincter 7. CVS: decreased peripheral resistance, decreased HR 10
- 11. Friedrich Wilhelm Adam Sertürner 1804 • 1783- 1841 • isolated morphine from opium in 1804 and sold it in 1817 • first person to isolate the active ingredient associate d with a medicinal plant or herb 11
- 12. MORPHEUS • God of dreams 12 Morpheus: greek god Of dreams
- 13. 13 Gold standard Natural substance Acts on CNS Gastric emptying/peristalsis Heroin is a precursor Morphine/heroin most addictive Psychological and physical dependence Tolerance analgesia, sedation, euphoria, physical dependence, and respiratory depression Peak Levels: IV/SQ 20 min PO 30 min Metabolized in liver Controlled substance Harrison Narcotic Tax Act of 1914
- 14. heroin • Diacetylmorphine discovered 1874 from morphine commercially available in 1898 Bayer • 1.5-2 times more potent than morphine • Lipid soluble therefore crosses BBB faster more addictive • Overtook morphine for choice drug of abuse once available 14
- 16. oxycodone • OxyContin is Purdue Pharma slow release oxycodone • Opioid synthesized in Germany 1916 thought to replace Heroin/Morphine • High risk of withdrawal • Peak plasma level one hour, 10 min onset • Excreted in urine/sweat watch for CRI • 50% weaker than Morphine • Abuse potential for snorting unlike Morphine and Heroin (must be injected) • Less stigma involved than Heroine/morphine • Street price $1 per mg • Percocet: Endo pharmaceuticals 16
- 17. 17 MORPHINE WITHDRAWAL -14 hours Drug craving, anxiety, irritability, perspiration, and mild to moderate dysphoria 4-18 hours Yawning, heavy perspiration, mild depression lacrimation, crying, running nose, dysphoria 16-24 hours Rhinorrhea, dilated pupils, piloerection (gooseflesh), muscle twitches, hot flashes, cold flashes, achi muscles, loss of appetite and the beginning of intestinal cramping. 24-36 hours severe cramping and involuntary leg movements “kick the habit”, loose stool, insomnia, elevation of sure, moderate elevation in body temperature, increase in frequency of breathing and tidal volume, tachycardia e), restlessness, nausea 6-72 hours fetal position, vomiting, free and frequent liquid diarrhea AL 7-10 days CHOLOGICAL: severe depression, anxiety, insomnia, mood swings, amnesia (forgetfulness), low self-esteem, conf anoia
- 19. A paradoxical response whereby the patient receiving opioids for the treatment of pain can become more sensitive to certain painful stimuli
- 20. 20 Cold pressor test: methadone People are sensitive
- 22. Opiate adverse effects postoperatively Constipation Hyperalgesia Confusion Respiratory depression Urinary dysfunction Tolerance Nausea Light headedness
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- 35. Neuromodulating agents Gabapentin: 1200 mg 1 hour preop? renal issues Pregabalin: 150 mg 1 hour preop Decreased opiate use, continue for one Week postop
- 38. 600 mg optimal dose for gabapentin?
- 39. Neuroaxial blockade • Epidural/intrathecal opioids • Respiratory depression • Direct steroidal application to inflamed root
- 40. 4g /day
- 43. Fatty liver in obesity
- 44. 200/500mg
- 45. options • Celebrex 200mg • Gabapentin/pregabalin • Extended release oxycodone • Acetaminophen • Lidocaine • Ketamine? • Clonidine? • Tramadol • steroids
- 46. THANKS!
- 52. • Some pain can be experienced as a pleasant experience i.e. Dominatrix 52
- 55. 55 Merck of Darmstadt, Germany 1827 commercial Morphine sold out of a single chemist’s shop
- 58. Controlled substances act 1970 • Schedules for “potential of abuse” • I:high potential no accepted medical use: Heroin, Marijuana?, psychotropic mushrooms • II: high potential for abuse but accepted for medical use: cocaine, ritalin, oxycodone, morphine, methadone, fentanyl, dilaudid, nucynta; no refills • III: less potential: hydrocodone with another drug;5 refills • IV: low potential: xanax, valium, ambien • V: lower: lyrica, cough suppressant, lomotil 58
- 59. 59 3 Methyl Morphine or Codeine Less potent than morphine and less dependency issues and withdrawal symptoms 1832 in France by Pierre Robiquet Most widely used opiate in the world In some countries it is available without prescription in combination preparations from licensed pharmacists in doses up to 15 mg/tablet in Australia, New Zealand, Poland, Romania (Codamin), and Costa Rica, 12.8 mg/tablet in the UK, 10 mg/tablet in Russia and Israel and 8 mg/tablet in Canada and Estonia
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