Sedation, Analgesia, and Local Anesthesia: A Review for General and Interventional Radiologists 1

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MULTISYSTEM RADIOLOGY

E47

Sedation, Analgesia, and Local Anesthesia: A Review for General and Interventional Radiologists1 ONLINE-ONLY SA-CME See www.rsna .org/education /search/RG

LEARNING OBJECTIVES After completing this journal-based SACME activity, participants will be able to: ■■Discuss

the Joint Commission requirements for sedation providers and typical hospital policy components with respect to patient care. ■■Identify

circumstances in which anesthesia consultations are most useful. ■■List

the different classes of sedatives, analgesics, and anesthetics and identify in what circumstances they are most applicable to the radiologist.

Thea C. Moran, MD • Alan D. Kaye, MD, PhD • Andrew H. Mai, MD Leonard R. Bok, MD, MBA, JD Radiologists, like other physicians, need to know how to use sedatives, analgesics, and local anesthetics; however, their exposure to patients requiring discomfort control is limited, not just during residency but also in postgraduate practice. The purpose of this article is to provide a reference guide for radiologists who need pertinent and ready information on discomfort control. The authors discuss policies and standards that the Joint Commission has established for sedation providers; also discussed are the clinical pharmacology and dosage recommendations for the sedative, analgesic, anesthetic, and reversal agents that radiologists are most likely to use. Monitored anesthesia care and patient-controlled analgesia pumps, and in what circumstances they may be appropriate, are discussed. Anesthesia consultations are not uncommon when a nonanesthesiologist needs either of these services. Stiff chest syndrome, serotonin release syndrome, and systemic toxicity due to local anesthesia, all life-threatening conditions that sedation and analgesia providers may encounter, are discussed. The causes of these conditions and their necessary treatments are included in the discussion, along with cases in which a nonanesthesiologist may need an anesthesia consultation. It is important to understand that the control of pain and anxiety are not mutually exclusive but can occur either separately or together; when an agent that controls anxiety and an agent that controls pain are given together, the overall effect is synergistic. It is also important to understand the concept of multimodal analgesia; this is the use of opioids and nonopioids together to take full advantage of the analgesic effects of each component while minimizing potential side effects. Radiologists are fully capable of providing effective and safe pain control on their own and with the assistance of an anesthesiologist. ©

RSNA, 2013 • radiographics.rsna.org

Abbreviations: ASA = American Society of Anesthesiologists, IV = intravenous, LAST = local anesthetic systemic toxicity, NSAID = nonsteroidal anti-inflammatory drug, PCA = patient-controlled analgesia RadioGraphics 2013; 33:E47–E60 • Published online 10.1148/rg.332125012 • Content Codes: From the Departments of Radiology and Anesthesia, LSU School of Medicine, 1542 Tulane Ave, 3rd Floor, New Orleans, LA 70112. Presented as an education exhibit at the 2011 RSNA Annual Meeting. Received February 13, 2012; revision requested April 3 and received August 22; final version accepted December 21. For this journal-based SA-CME activity, the authors, editor, and reviewers have no relevant relationships to disclose. Address correspondence to T.C.M. (e-mail: [email protected]). 1

©

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Introduction

Managing patient discomfort has always been important, but it has become especially important for physicians, given the current licensure, credentialing, and legal consequences of poor discomfort control. In 2003, the Federation of State Medical Boards of the United States called for an update to the Model Guidelines for the Use of Controlled Substances for the Treatment of Pain so that state medical boards could identify the inappropriate treatments of pain, including undertreatment, as departures from accepted medical practice (1). There are national standards (2) outlined by the Joint Commission (formerly known as the Joint Commission on Accreditation of Healthcare Organizations) with regard to assessment and management of pain. Healthcare providers have been held legally responsible for poor pain control (3). Despite the apparent need to manage pain, it is often undertreated. An obstacle to good pain control is lack of physician experience and education. Radiologists are an example of physicians who, in general, have limited experience in cases requiring pain control. This, however, does not mean that instances in which pain control is necessary do not occur in the radiology department. Biopsy and drainage procedures are painful, as are contrast material extravasations and placement of intravenous (IV) lines. Sedation may be needed in patients undergoing magnetic resonance (MR) imaging or computed tomography (CT). Inpatients may require pain or sedation orders while they wait for an examination or procedure. These cases may be managed parenterally, but knowledge of nonparenteral pain control is also important. With the impetus for shorter hospital stays and outpatient treatment centers, radiologists need to know how to prescribe oral pain medications as well. The objective of this article is to provide a sedation, analgesia, and local anesthesia reference guide for the busy radiologist. Joint Commission requirements for healthcare providers who administer sedation are discussed. Medications are discussed in the text, and tables with dosages for the best known and most applicable agents are provided. Also discussed are the circumstances in which use of the anesthesia team is most appropriate.

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General Concepts and Policies Sedation Sedation is the administration of medications that calm the nervous system. Sedatives decrease awareness and responsiveness to external stimuli. They reduce anxiety, thereby making the psychological unpleasantness of a procedure tolerable. Anxiety potentiates the perception of pain; therefore, good sedation facilitates good pain control. Some sedatives have amnestic properties that are especially advantageous to patients anticipating multiple unpleasant procedures. Sedated patients are more likely to remain immobile, thus resulting in a quicker, safer, and more sterile procedure. Sedation is classified on a continuum. Four levels of sedation are identified by the American Society of Anesthesiologists (ASA): minimal sedation, moderate sedation, deep sedation, and general anesthesia (Table 1) (4). If the potential for respiratory depression and airway compromise exists, as in the case of moderate and deep sedation, the Joint Commission requires that providers of non-anesthesia sedation perform a preoperative evaluation of patients and monitor them while they are receiving sedation and during the recovery period (5). Quality and practice improvement programs exist and are especially important when sedation is performed by both anesthesia providers and nonanesthesiologists (5). Nonanesthesiologists may be credentialed to perform moderate or deep sedation. No credentialing is necessary for minimal sedation. If radiologists are credentialed to perform sedation, they are usually credentialed to perform moderate sedation. Sedation policies have been implemented at many hospitals. The overall goal of a procedural sedation program is to provide the best standard of care that yields the best outcome for patients in all settings. This program starts with the development of a comprehensive, practical policy that provides an institutional philosophy as a basis for sedation care standards (5). Preprocedure assessment and patient monitoring requirements are integral to sedation policies. Sedation consists of three phases: preprocedural assessment, intraprocedural monitoring, and postprocedural monitoring. Each phase has specific requirements intended to ensure patient safety.

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Table 1 Effects of ASA Levels of Sedation Level of Sedation

Responses to Stimuli

Minimal

Normal response to verbal stimulation Purposeful response to verbal or tactile stimulation Purposeful response after repeated or painful stimulation Unarousable, even with painful stimulus

Moderate

Deep General anesthesia

Spontaneous Ventilation

Airway

Cardiovascular Function

Unaffected

Unaffected

Unaffected

No intervention required

Adequate

Usually maintained

Intervention may be required

May be inadequate

Usually maintained

Intervention often required

Frequently inadequate

May be impaired

Source.—Reference 4.

Analgesia

Local Anesthesia

Analgesia is the symptomatic relief of pain with use of pharmacologic agents. Pain signals are received, but medication prevents the perception of the pain. Analgesics can be classified as either opioid or nonopioid. Opioids are drugs with opium- or morphine-like pharmacologic action. They act on opioid receptors in the peripheral and central nervous systems. Opiates are either natural alkaloids or synthetic derivatives. They are potent analgesics and are used to treat pain associated with injury, surgery, and medical conditions. They also have sedative, antitussive, and antirigor properties. Opioids are associated with undesirable side effects such as nausea, constipation, and central nervous system and respiratory depression. Long term, opioid use can lead to tolerance and addiction. The actions of opioids are augmented when they are administered with benzodiazepines. Opioids have no maximal dose; they are titrated to effect. Nonopioid analgesics are reserved for less severe pain and are not used intraprocedurally. They are not associated with dependency and are the most used drugs worldwide. Their side-effect profiles factor into which nonsteroidal anti-inflammatory drug (NSAID) is most appropriate for a given patient at a given time.

Anesthesia is the pharmacologic blocking of pain signal reception by the nervous system. Anesthesia may be general, regional, or local. Local anesthesia is the type most often used by radiologists. Local anesthetics stabilize nerve membranes by reversibly binding to sodium channels. Local anesthesia can be topical or infiltrative. Topical anesthesia is used to numb the surface of a body part. Infiltrative anesthetics are injected subcutaneously. Local anesthetics are divided into amides and esters; amides are more commonly used because they are, in general, more potent and longer acting.

Single or Combination Therapy Sedation, analgesia, and local anesthesia can be used alone or in concert, depending on the clinical circumstance. For example, when local anesthesia alone is insufficient to provide pain relief, IV opioid analgesia can be added. This is often the case during interventional procedures. Opioids ameliorate pain but do not treat the anxiety a patient may experience undergoing an invasive procedure in an unfamiliar environment. Not only is anxiety unpleasant for patients, but pain is more resistant to analgesics when the patient is anxious. Sedatives

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Figure 1.  Schematics of, A, Mallampati scoring classes during an airway examination and, B, visualization grades during direct laryngoscopy (5).

treat the anxiety. When used together, sedatives and opioid analgesics act synergistically, enhancing each other’s effects. Local anesthetics, sedatives, and opioids can be used alone. Examples of cases in which they might be used alone are topical anesthetic applied to a small child before placement of an IV line, a sedative given to a claustrophobic patient before the patient undergoes MR imaging, and the prescription of an oral opioid for an outpatient complaining of cramping after hysterosalpingography.

Patient Selection and Assessment

Presedation is the first phase in the care of a patient undergoing moderate or deep sedation. The following measures should be completed before starting sedation: documented patient evaluation (history and physical examination within 30 days of the procedure and an update within 24 hours); documented discussion, including risks and benefits, and consent; documented plan for sedation; assurance that the appropriate personnel and equipment are in place; and documented identification of the patient. Prevention of complications starts with a thorough preprocedural patient assessment (5). Age is an important factor to consider when administering sedation because metabolism and elimination are altered. Older patients frequently need a 30%–50% reduction in dose and more frequent dose intervals. Doses may also need to be decreased if kidney or liver function is impaired. On the other hand, people who are habituated to opioids or benzodiazepines may need higher doses than would normally be

expected. Smoking is the main cause of periprocedural respiratory morbidity and mortality; therefore, cessation should be encouraged before sedation, if possible. Obesity, abnormalities of the neck, tongue, or teeth, and restricted mouth opening can lead to difficult airway management. The oropharynx should be examined, and a modified Mallampati score should be determined (Fig 1). A high Mallampati score, short distance between chin and thyroid cartilage, restricted mouth opening, short thick neck, and other abnormalities predict difficult intubation and difficult or impossible mask ventilation and should alert the practitioner or physician that the patient is a poor candidate for moderate or deep sedation and may be difficult to intubate in an emergency (5). A medication history, including supplements and prior reactions or allergies to medications and sedatives, must be obtained. Cardiovascular diseases such as hypertension, myocardial infarction within the previous 6 months, congestive heart failure, and arrhythmias indicate an increased risk of periprocedural complications. A respiratory status report should include whether the patient has asthma, chronic obstructive pulmonary disease, or other lung diseases. A gastrointestinal status report should include a history of gastroesophageal reflux, peptic ulcer disease, and nil per os (NPO) status. Fasting status is important as a predictor of aspiration, and it should be noted that fasting guidelines vary among institutions. Cardiovascular medication should be continued. Blood sugar levels should be routinely monitored in all patients with diabetes. If the procedure is emergent and the patient is not fasting, metoclopramide (Reglan) (10 mg IV) and an H2 blocker (eg, famotidine [Pepcid]) (10

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Table 2 ASA Physical Status Classifications Class I II III IV V VI E

Status Normal healthy patient without systemic disease Mild to moderate systemic disease (ie, controlled hypertension, diabetes) or elderly Severe systemic disease (ie, limited activity but not incapacitating) Severe systemic disease (constant threat to life and incapacitating) Moribund and will die within 24 hours without surgical intervention Patient who is brain dead and undergoing anesthesia care for purposes of organ donation This modifier is added to any of the classes to signify a procedure that is being performed as an emergency and may be associated with a suboptimal opportunity for risk modification

Note.—Reprinted, with permission, from reference 5.

mg IV) can be administered to enhance stomach emptying and reduce the chance of aspiration. The ASA physical status is determined after consent is obtained (Table 2). Providers credentialed only for moderate sedation should not provide sedation to patients with an ASA physical status above III. Resuscitation equipment should be available in the procedure room should advanced cardiovascular life support be needed. Anesthesia backup should be available, and good communication with regard to highest-risk patients is essential. The purpose of the presedation assessment is to determine the level of sedation the patient needs and that the sedation can be administered safely, and whether the nonanesthesiologist is equipped to administer that level of sedation. When the nonanesthesiologist is not equipped to administer the level of sedation needed safely, the provider may request an anesthesia consultation for monitored anesthesia care. Monitored anesthesia care is the administration of sedation under the supervision of an anesthesiologist. The essential component of monitored anesthesia care is the assessment and management of anticipated physiologic changes during the procedure, with the provider of the anesthetic prepared and qualified to convert to general anesthesia, if necessary (5). Examples of patients who may benefit from monitored anesthesia care include those with Pickwickian syndrome or sleep apnea (5); both have tenuous airways that have the potential for obstruction. Patients who poorly tolerate invasive procedures or are undergoing painful procedures may require deep sedation. Deep sedation depresses consciousness; patients can be aroused only with painful stimuli. Although deep sedation is an effective anxiolytic technique, the ability to independently maintain ventilatory function may be impaired. Patients requiring deep sedation usually need monitored anesthesia care. Radiologists are rarely credentialed to administer deep sedation. A discussion of the most common deep sedatives is included in the next section.

Medications Sedatives Sedatives for Minimal and Moderate Sedation.—

Sedatives act on the nervous system by a variety of mechanisms. The most common types of sedatives are benzodiazepines. They facilitate the actions of g-aminobutyric acid, the main inhibitory neurotransmitter in the central nervous system. Benzodiazepines act synergistically with opioids; they possess anxiolytic and amnestic properties. Most sedatives can be administered by a variety of routes, but IV is the most commonly used route before and during the procedure. Midazolam (Versed), lorazepam (Ativan), and diazepam (Valium) are all benzodiazepines. In addition to anxiolysis and amnesia induction, diazepam has anticonvulsant properties. Midazolam is the most common benzodiazepine used intraprocedurally because of its potency, rapid onset of action, and relatively short elimination half-life (1–4 hours) (6). Midazolam can be administered either intramuscularly or intravenously. Lorazepam can be administered orally as well as intramuscularly and intravenously and has a mean elimination half-life of 15 hours (7) and a variable peak effect after IV injection (8); therefore, it is a less desirable agent, especially if the anticipated procedure length is short. Diazepam (including active metabolites) has an elimination half-life of 20–100 hours (7), thus making it a less desirable procedural agent. Diazepam is also painful with IV injection, but it can also be administered intramuscularly or orally. Diphenhydramine (Benadryl) is a sedative that blocks histamine-1 receptors. It is most commonly used in the radiology department for pretreatment of contrast reactions. Diphenhydramine has anticholinergic properties that limit its use in asthma, narrow angle glaucoma, and urinary retention.

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Table 3 Adult Parenteral Dosing for Sedatives Brand Name

Agent

How Supplied

Valium

Diazepam

5 mg/mL inj

Benadryl

Diphenhydramine

50 mg/mL inj

Ativan

Lorazepam

2, 4 mg/mL inj

Versed

Midazolam

1, 5 mg/mL inj

Dosing 2–10 mg IM/IV q 3–4 hrs prn anxiety Max 30 mg 10–50 mg IV or up to 100 mg IM prn anxiety Max 400 mg/d 0.05 mg/kg IM 2 hrs preoperative; 2 mg or 0.0444 mg/kg (whichever is smaller) IV prn anxiety Max 4 mg/d IM or IV 1–2.5 mg IV over 2 mins prn anxiety; titrate to effect q 2 mins Max 5 mg total dose

Source.—Reference 9.

The anticholinergic properties also contribute to side effects such as dry mouth, dizziness and sedation, which are exacerbated by concomitant use of certain medications, including MAO inhibitors. Adult parenteral dosages for sedatives are given in Table 3. Sedatives for Deep Sedation.—Propofol, etomi-

date, and ketamine are all examples of deep sedatives. Propofol (Diprivan) is a popular deep sedative because of its fast onset time, fast recovery, and easy titratability. There are few residual effects after infusion is discontinued and a low occurrence of nausea and vomiting. Propofol can cause low oxygen and increased carbon dioxide levels and inhibit airway reflexes; it also has a narrow therapeutic range. Etomidate (Amidate) is a deep sedative with hypnotic (without analgesic) properties. It produces minimal hemodynamic effects at clinically relevant doses, which makes it especially useful in patients with limited hemodynamic reserve. Its effect is rapid, and it has a residual depressant effect. Involuntary myoclonic movements are common with etomidate, but these can be attenuated with a prior administration of an opioid. It is associated with a higher occurrence of nausea and vomiting than propofol and is painful on injection; it can also transiently depress adrenocortical function. Ketamine (Ketalar) is a phencyclidine derivative that induces a dissociative state and analgesia. It is fast acting, with a return to consciousness within 15 minutes after a single dose (5). Respiratory depression is minimal, so it is especially useful in patients susceptible to ventilatory depression. Hypertonus and purposeful skeletal muscle movements often occur with ketamine; it also causes

sympathetic nervous system stimulation and bronchodilation with increased respiratory secretions. The sympathetic nervous system stimulation can cause an increase in blood pressure, heart rate, and cardiac output, but this can have the opposite effect in the critically ill, as a result of depletion of catecholamine stores. Unpleasant emergence can occur, but this can be lessened by concomitant use of a benzodiazepine.

Analgesics Opioids: Intraprocedural Agents.—The intrapro-

cedural opioids used at our institution are morphine, fentanyl, and hydromorphone (Dilaudid). Meperidine (Demerol) is another intraprocedural opioid. It should be mentioned that many opioid medicines are available and that the same preparation may be manufactured by different companies under different names. Table 4 provides a list of opioids most likely to be encountered by radiologists. Morphine and many codeine derivatives are used to treat moderate to severe pain. Morphine is supplied in tablet (sustained released and immediate release), solution, suppository, and injectable forms. Morphine is glucoronidated to morphine-6glucoronide, an active metabolite that is eliminated by the kidneys. In patients with kidney failure, therefore, morphine is contraindicated. Morphine also releases the most histamine relative to that released by other opioids and should not be used in asthmatic and hypotensive patients. Fentanyl is a synthetic intraprocedural opioid with 50 to 100 times the potency of morphine; it is short acting, with fewer overall side effects than those associated with morphine. Fentanyl is associated with stiff chest syndrome, a rare but serious condition caused by rapid IV administra-

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Table 4 Adult Dosing for Analgesics: Opioids Brand Name

Composition

Tab/Solution/Inj

Tylenol with codeine (PRICARA) Tylenol 3

Codeine/ acetaminophen

Solution

Codeine/ acetaminophen

Tablet

Tylenol 4

Codeine/ acetaminophen

Tablet

Sublimaze

Fentanyl

Injectable

Dilaudid Dilaudid Dilaudid

Hydromorphone Tablet Hydromorphone Solution Hydromorphone Injectable

Lorcet

Hydrocodone/ acetaminophen

Tablet

Lortab

Hydrocodone/ acetaminophen

Tablet

Hycet

Hydrocodone/ acetaminophen

Solution

Demerol

Meperidine

Tablet

Demerol Demerol

Meperidine Meperidine

Solution Injectable

tion of fentanyl. The syndrome results in rigidity of skeletal muscles, including the intercostal muscles. Treatment is with succinylcholine and airway management (usually intubation) while the fentanyl-mediated effects are being reversed. Fentanyl is also supplied in tablet, lozenge, transdermal, buccal, and nasal spray forms. Hydromorphone (Dilaudid) is a semisynthetic derivative of morphine. It has four to eight times the potency of morphine, with fewer side effects, and has antitussive effects in addition to analgesia. In addition to the injectable form, it is available in tablet, liquid, and rectal suppository forms. Meperidine (Demerol) is a parenteral opioid that requires separate discussion. It has one-tenth the potency of morphine, with local

How Supplied

Dosing

12/120 mg/5 mL

15 mL po q 4 hrs prn pain Codeine max 15/60 mg/d Acetaminophen 4000 mg/d 30 mg codeine/300 15–60 mg po q 4 hrs prn pain mg acetaminophen Codeine max 15/60 mg/d Acetaminophen 4000 mg/d 60 mg codeine/300 15–60 mg po q 4 hrs prn pain mg acetaminophen Codeine max 15/60 mg/d Acetaminophen 4000 mg/d 50 µg/mL vial 50–100 µg IV titrate to effect; repeat q 1–2 hrs prn pain postoperative Total dose 2 µg/kg 2, 4, and 8 mg/tab 2–4 mg po q 4–6 hrs prn pain 1 mg/mL 2.5–10 mg po q 4–6 hrs prn pain 1, 2, or 4 mg/mL 1–2 mg SC/IM q 2–3 hrs prn pain; 1–2 mg IV (slowly over 2–3 mins) titrate to effect 7.5 or 10 mg 1 tab q 4–6 hrs prn pain Hydrocodone/650 mg Max 6 tabs/d acetaminophen 5, 7.5, 10 mg hydro- 1 tab q 4–6 hrs prn pain codone/500 mg Max 6 tabs/d for 7.5 and 10 mg, acetaminophen 8 tabs/d for 5 mg 7.5 mg hydroco15 mL q 4–6 hrs prn pain done/325/500 mg Max 90 mL/d acetaminophen/15 mL 50, 100 mg 50–150 mg po q 3–4 hrs prn pain 50 mg/5 mL 50–150 mg po q 3–4 hrs prn pain 25, 50, 75, 100 mg/ 50–150 mg IM/SQ q 3–4 hrs mL prn pain (reduce dose and inject slowly if IV) (continues)

anesthetic and antirigor properties, and is associated with less sedation and itching; however, it has other concerning side effects. It has atropine-like effects that result in dry mouth, tachycardia, and pupil dilation and is a myocardial depressant. Meperidine is metabolized to normeperidine, which is a central nervous system stimulant; therefore, seizure risk exists in cases of renal insufficiency or with high doses. It also interacts with many prescription drugs and over-the-counter medications (eg, Prozac and St John’s wort). Coadministration of serotonin reuptake inhibitors with meperidine can cause serotonin syndrome, a life-threatening adverse drug reaction resulting in autonomic instability

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Table 4 (continued) Adult Dosing for Analgesics: Opioids Brand Name

Composition

Tab/Solution/Inj

How Supplied

Dosing

Morphine sulfate immediate release Morphine sulfate immediate release Morphine (MS Contin) Astra or Duramorph OxyContin

Morphine

Tablet

15, 30 mg

15–30 mg po q 4 hrs prn pain

Morphine

Solution

10, 20, 100 mg/5 mL

10–20 mg q 4 hrs prn pain

Morphine

Tablet

Individualize dose

Morphine

Injectable

15, 30, 60, 100, 200 mg 0.5, 1 mg/mL

Oxycodone

Tablet

OxyIR Percocet

Oxycodone Oxycodone/ acetaminophen

Tablet Tablet

Percodan

Oxycodone/ ASA Hydrocodone/ acetaminophen

Tablet

Hydrocodone/ acetaminophen

Tablet

Vicodin

Vicodin ES

Tablet

2–10 mg/70 kg IV–titrate to effect 10, 15, 20, 30, 40, 60, Individualize dose 80 mg 5 mg 5 mg po q 6 hrs prn pain 2.5, 5, 7.5, 10 mg/325 1 tablet po q 6 hrs prn pain mg acetaminophen; Max 6–8 tabs/d 7.5 mg/500 mg  acetaminophen; 10 mg/650 mg  acetaminophen 5 mg oxycodone/325 1 tab po q 6 hrs prn pain mg ASA Max 12 tab/d 5 mg hydrocodone/ 1–2 tab po q 4–6 hrs prn pain   500 mg acetamino- Max 8 tabs/d phen 7.5 mg hydroco1 tab po q 4–6 hrs prn pain done/750 mg Max 5 tabs/d acetaminophen

Source.—Reference 9.

with hypertension, tachycardia, hyperreflexia, diaphoresis, hyperthermia, and agitation. For these reasons, meperidine is a second-line analgesic. Meperidine use at our institution is limited to patients with sepsis-related rigors in the recovery room. Opioids: Agents Not Used Intraprocedurally.—

Codeine, hydrocodone, and oxycodone are opioids that are not used during procedures. They are available in nonparenteral forms and are often combined with nonopioids to decrease their respective doses. Combining nonopioids with these opioids improves the clinical effectiveness of the opioids without increasing the risk of their side effects. The most common nonopioids used in combination with opioids are acetaminophen and aspirin. The maximum dosage for the combination agent is its maximum dosage when used alone. Exceeding the maximum dosage of the nonopioid increases the risk of side effects due to the nonopioid. The administration of a combination of opioid and nonopioid analgesics for this purpose is multimodal analgesia (10). A list of these combination

agents, with composition and dosages, can be found in Table 4. Codeine is an opioid that is used both as an antitussive agent and an analgesic and is available in tablet, suspension, and injectable forms. It is combined with a nonopioid in varying concentrations. Hydrocodone is a semisynthetic derivative of codeine that also has antitussive properties and can be administered with a nonopioid in various combinations (Vicodin, Lorcet, and Lortab). These formulations are available in tablet form only. Oxycodone is a semisynthetic derivative of thebaine, another opioid, and can be combined with acetaminophen or aspirin to form Percocet and Percodan, respectively. Nonopioids.—Nonopioids are not typically used

intraprocedurally and are best reserved for outpatient use. Nonopioids in use are acetaminophen and NSAIDs. Acetaminophen can cause liver toxicity when taken in excess of 4 g per day but poses no gastrointestinal tract or bleeding risk. NSAIDs are more effective for treating inflammation but have side effects that can potentially affect cardiac, gastrointestinal, and renal systems. NSAIDs can also interfere with normal platelet

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Table 5 Adult Dosing for Analgesics: Nonopioids Brand name

Component

Tab/Solution/Inj

How Supplied

Tylenol

Acetaminophen

Tablet

325, 500, 650 mg

Tylenol

Acetominophen

Solution

500 mg/15 mL

Aspirin (extra strength) Celebrex

ASA

Tablet

500 mg

Celecoxib

Tablet

50, 100, 200, 400 mg

Dolobid

Diflunisal

Tablet

500 mg

Motrin IB

Ibuprofen

Tablet

200 mg

Indocin

Indomethacin

Capsule

25, 50 mg

Indocin

Indomethacin

Solution

25 mg/5 mL

Toradol

Ketorolac

Tablet

10 mg

Toradol

Ketorolac

Injectable

15, 30 mg/mL

Aleve

Naproxyn

Caplet

220 mg

Naprosyn

Naproxyn

Tablet

250, 375, 500 mg

Naprosyn

Naproxyn

Solution

125 mg/5 mL

Dosing 500–1000 mg po q 4–6 hrs pain Max 4000 mg/d 500–1000 mg po q 4–6 hrs prn pain Max 4000 mg/d 1–2 tabs po q 4–6 hrs prn pain Max 4000 mg/d 400 mg po day 1 then 200 mg po BID prn pain 1000 mg po initially then 500 mg po q 8–12 hrs prn pain Max 1500 mg/d 200 mg po q 4–6 hrs prn pain Max 1200 mg/d 25–50 mg po q 8–12 hrs prn pain Max 150–200 mg/d 25–50 mg po q 8–12 hrs prn pain Max 150–200 mg/d Transition from IV to po: 20 mg po then 10 mg po q 4–6 hrs prn pain Max 40 mg/d < 5 d 30 mg IM/IV q 6 hrs prn pain

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