Acute pain management pearls ..Part 3..NSAIDS and paracetamol

Paracetamol is an effective analgesic for acute pain; the incidence of adverse effects comparable to placebo.

Level I Cochrane reviewNon-selective NSAIDs are effective in the treatment of acute postoperative and low back pain, renal colic and primary dysmenorrhoea (Level I Cochrane review )

With careful patient selection and monitoring, the incidence of nsNSAID-induced perioperative renal impairment is low.(Level I chocrane review)

Non-selective NSAIDs do not increase the risk of reoperation for bleeding after tonsillectomy in paediatric patients.

(Level I Cochrane review)

Coxibs do not appear to produce bronchospasm in individuals known to have aspirinexacerbated respiratory disease.(level I)

Paracetamol given in addition to PCA opioids reduces opioid consumption but does not result in a decrease in opioid-related side effects.( Level I)

Preoperative coxibs reduce postoperative pain and opioid consumption, and increase patient satisfaction.(level I)

Perioperative non-selective NSAIDs increase the risk of severe bleeding after a variety of other operations compared with placebo.(level II)

Coxibs do not impair platelet function; this leads to reduced perioperative blood loss in comparison with non-selective NSAIDs.

The risk of adverse renal effects of non-selective NSAIDs and coxibs is increased in the presence of factors such as pre-existing renal impairment, hypovolaemia, hypotension, use of other nephrotoxic agents and ACE inhibitors

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The pressure volume loop...

In the pressure-volume loop below, cardiac work is best represented by: the area of the curve the slope of the line from points C to D the distance of the line from points C to D the slope of a line from points A to D .. .. ... .... ... .... .... .... In the pressure-volume loop below, cardiac work is best represented by: the area of the curve Cardiac work is the product of pressure and volume and is linearly related to myocardial oxygen consumption. Cardiac work is best represented by the area of the curve of a pressure-volume loop.

Anaphylaxis updates part 2- Empty Ventricle Syndrome

Patients with anaphylaxis should not suddenly sit, stand, or be placed in the upright position. Instead, they should be placed on the back with their lower extremities elevated or, if they are experiencing respiratory distress or vomiting, they should be placed in a position of comfort with their lower extremities elevated. This accomplishes 2 therapeutic goals: 1) preservation of fluid in the circulation (the central vascular compartment), an important step in managing distributive shock; and 2) prevention of the empty vena cava/empty ventricle syndrome, which can occur within seconds when patients with anaphylaxis suddenly assume or are placed in an upright position. Patients with this syndrome are at high risk for sudden death. They are unlikely to respond to epinephrine regardless of route of administration, because it does not reach the heart and therefore cannot be circulated throughout the body

Steroids In Perioperative period...The Multi-purpose Drugs

1-Steroids are not Bronchodilator ,but have well established usefulness in hyper-reactive airway. They are also said to have a permissive role for bronchodilator medication. They can be administered orally, parenterally or in aerosol form 2- Steroids have been commonly used in chemotherapy for prevention of nausea along with other anti-emetic agents . Dexamethasone was found to be highly effective when given immediately before induction rather than at the end of anesthesia . 3- Steroids do exert analgesic effects. Various routes of administration of steroids include parentral, local infiltration at operated site , as an adjuvant in nerve blocks and central-neuraxial blockade. 4 - Steroids cannot be the mainstay of therapy in anaphylaxis because of the delayed onset of action, so they are used as adjunct after initial treatment with epinephrine. 5- Steroids (Dexamethsone) are of value in reduction or prevention of cerebral edema associated with parasitic infections and neopla...

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