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121. CRACKCast E194 – Pain Management

rate decreased or increased Blood pressure decrease or unchanged Respiratory rate decreased Temperature decreased or unchanged Gastrointestinal: Decreased bowel sounds Neurological: Sedation or coma Seizure (Meperidine, propoxyphene, tramadol, or as a result of hypoxia) Vs. Side effects (multiple) New: risk factor for invasive pneumococcal disease and other infections Opioid Analgesic Use and Risk for Invasive Pneumococcal Disease: A Nested Case-Control Study – Wiese et al. Constipation (reduced

2018 CandiEM

122. CRACKCast E160 – Lithium

in serotonin syndrome when combined with other drugs, such as monoamine oxidase (MAO) inhibitors, selective serotonin reuptake inhibitor (SSRIs), dextromethorphan, and meperidine Any changes in renal excretion due to conditions such as dehydration, hyponatremia, or renal dysfunction will lead to increases in serum lithium levels. [2] List the ECG changes potentially seen in lithium toxicity These are usually seen in acute overdose Bradycardia Junctional rhythm / AV blockade ST changes QT prolongation

2018 CandiEM

124. Management of Acute Pancreatitis in the Pediatric Population: A Clinical Report From the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Pancreas Committee

to manage children with AP according to the 2012 INSPPIRE physician questionnaire (102). Morphine had been reported to cause sphincter of Oddi dysfunction after systemic administration (103). No clear evidence, however, supports this theory and morphine can be used safely in patients with AP (104). Meperidine has been used in adults with AP but drawbacks include its short half-life and potential of neurotoxicity through the buildup of toxic neurometabolites that can lead to seizures, myoclonus (...) , and tremors (105). A review of narcotics and sphincter of Oddi function by Thompson (106), documents that no studies to date directly compare the effects of meperidine and morphine on sphincter of Oddi manometry and no comparative studies exist in patients with AP. Furthermore, no studies or evidence exist to indicate morphine is contraindicated for use in AP. A Cochrane review from 2013 includes 5 studies with a total of 227 subjects to assess the efficacy and safety of several opioids. Medications

2018 North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition

125. Practice Guidelines for Moderate Procedural Sedation and Analgesia Full Text available with Trip Pro

benzodiazepines ( e.g. , midazolam, diazepam, flunitrazepam, lorazepam, or temazapam) and dexmedetomidine. Analgesics administered with sedatives include opioids such as fentanyl, alfentanil, remifentanil, meperidine, morphine, and nalbuphine. This section of the guidelines addresses the following topics: (1) benzodiazepines and dexmedetomidine, (2) sedative/opioid combinations, (3) intravenous versus nonintravenous sedatives/analgesics not intended for general anesthesia, and (4) titration of sedatives (...) dexmedetomidine is combined with an opioid analgesic compared with midazolam combined with an opioid analgesic (category A3-B evidence). One RCT reports deeper sedation ( i.e. , higher sedation scores) and a lower frequency of hypoxemia when dexmedetomidine combined with midazolam and meperidine is compared with midazolam combined with meperidine (category A3-B evidence). One RCT comparing intravenous midazolam with intramuscular midazolam reports equivocal findings for oxygen saturation levels, respiratory

2018 American Society of Anesthesiologists

126. Guidelines for sedation and anesthesia in GI endoscopy

sedation (ie, a benzodiazepine plus narcotic), with respect to safety, patient and provider satisfaction, and induction and recovery times. Two randomized controlled trials compared NAPS for colonoscopy with a combination regimen of midazolam and fentanyl 57 and midazolam plus meperidine. 58 All studies found that NAPS exhibited signi?cantly shorter recovery times. There were no signi?cant differences across sedation regimens in the incidence of bradycardia, hypotension, hypoxemia, physician (...) . 50. Cohen LB, Hightower CD, Wood DA, et al. Moderate level sedation during endoscopy: a prospective study using low-dose propofol, meperidine/fentanyl, and midazolam. Gastrointest Endosc 2004;59: 795-803. 51. Rex DK, Overley C, Kinser K, et al. Safety of propofol administered by registered nurses with gastroenterologist supervision in 2000 endo- scopic cases. Am J Gastroenterol 2002;97:1159-63. 52. HeussLT,SchnieperP,DreweJ,etal.Riskstratificationandsafeadmin- istration of propofol by registered

2018 American Society for Gastrointestinal Endoscopy

127. CRACKCast E162 – Opioids

, methadone, and meperidine. Opioids are a major cause for concern today – in overdose they cause respiratory depression and death. In 2010 alone, enough prescription opioids were prescribed to medicate every American adult with 5 mg of hydrocodone every 4 hours for 1 month. Consequently, the United States has seen a widespread rise in prescription opioid abuse, overdoses, and deaths. In 2010, approximately 12 million Americans, or 1 in 20, reported use of opioids without a prescription. Nearly 15,000 (...) overdose or overdose of unknown substance! 1) List 6 commonly abused opioids (Table 156:1) Heroin (semisynthetic) Codeine (in its various forms e.g. Tylenol #3) Fentanyl Hydromorphone Morphine Methadone Oxycodone Meperidine 2) Describe the opioid toxidrome (list opioid effects on Neuro, Resp, Ophtho, CV, GI, Derm) Opioids act on receptors in the central nervous, cardiovascular, pulmonary, and gastrointestinal systems and can also be used therapeutically for their antitussive and antidiarrheal effects

2018 CandiEM

128. Palliative Care for the Patient with Incurable Cancer or Advanced Disease: Part 2: Pain and Symptom Management

transdermal or methadone a morphine b , codeine, meperidine c Compliance and convenience time release formulations (e.g., morphine, hydromorphone, oxycodone) Neuropathic pain oxycodone or methadone d (anecdotal evidence) Opioid naïve low dose morphine, hydromorphone or oxycodone fentanyl transdermal patch (risk of delayed absorption and overdose potential), sufentanil Injection route (e.g., SC) morphine, hydromorphone, second line: methadone by buccal or rectal route e oxycodone (injectable (...) ) is not available in Canada Patient is at extreme risk of respiratory depression Buprenorphine transdermal patch f a Fentanyl is primarily (75%) cleared as inactive metabolites by the kidney and methadone is cleared hepatically. b Morphine is the least preferred in renal failure because of renally cleared active metabolites. c Meperidine (Demerol®) should not be used for the treatment of chronic pain. d If a patient in your practice is started on methadone by a palliative care physician, in order to renew

2017 Clinical Practice Guidelines and Protocols in British Columbia

130. Analgesia and Anesthesia for the Breastfeeding Mother

, single doses of meperidine/pethidine or diazepam are unlikely to affect the breastfeeding infant. 15 (III) Local anesthetics given by injection or topical application are considered safe for breastfeeding mothers. 2,3 (IV) Regional anesthesia. Regional anesthesia, including spinal, epidural, or peripheral nerve block, should be con- sidered whenever possible, whether for intraoperative anes- thesia or postoperative analgesia. 3 (IV) Regional anesthesia reduces the need for intraoperative medications (...) , but its safety pro?le is likely similar to fentanyl. 36 Thisopioidismostcommonlyusedduring general anesthesia, or as an additive in epidural an- esthesia and analgesia. Meperidine. The transfer of meperidine/pethidine intobreastmilkislow(1.7–3.5%ofmaternalweight- adjusted dose). However, meperidine/pethidine and its metabolite (normeperidine) are consistently asso- ciated with dose-related neonatal sedation. Transfer into milk and neonatal sedation have been docu- mented for even up to 36 hours after

2017 Academy of Breastfeeding Medicine

131. Chronic pain disorder medical treatment guideline.

) is not recommended for most chronic pain patients due to methods of administration, reports of euphoria in some patients, and lack of proof for improved efficacy in comparison with other opioids. Codeine with acetaminophen Fentanyl (Actiq, Duragesic, Fentora, Sublimaze) is not recommended for use with musculoskeletal chronic pain patients. Meperidine (Demerol) is not recommended for chronic pain. Methadone Morphine Oxycodone and hydromorphone Propoxyphene (Darvon, Davon-N, PP-Cap) Tapentadol (Nucynta

2017 National Guideline Clearinghouse (partial archive)

132. Complex regional pain syndrome/reflex sympathetic dystrophy medical treatment guideline.

. Meperidine (Demerol) is not recommended for chronic pain. Methadone Morphine Oxycodone and hydromorphone Propoxyphene (Darvon, Davon-N, PP-Cap) has been withdrawn from the market due to cardiac effects including arrhythmias. Tapentadol (Nucynta) Tramadol (Rybix, Ryzolt, Ultram) Primary laboratory monitoring is recommended for acetaminophen/aspirin/NSAIDs combinations (renal and liver function, blood dyscrasia), although combination opioids are not recommended for long-term use. There is some evidence

2017 National Guideline Clearinghouse (partial archive)

133. Opioid Use and Opioid Use Disorder in Pregnancy

half-life, and to avoid opioid withdrawal symptoms, a physically dependent heroin user will need to take multiple doses daily. Prescribed opioids such as codeine, fentanyl, morphine, methadone, oxycodone, meperidine, hydromorphone, hydrocodone, propoxyphene, and buprenorphine all have the potential for misuse. These products may be swallowed, injected, nasally inhaled, smoked, chewed, or used as suppositories ( ). The onset and intensity of effect will vary based on how the drug was taken (...) of observational studies. Earlier reports have not shown an increase in risks of birth defects after prenatal exposure to oxycodone, propoxyphene, or meperidine ( , ). An association between first-trimester use of codeine and congenital abnormalities has been found in some studies ( ) but not in others ( , ). The authors of one retrospective study observed an increased risk of several birth defects with the use of prescribed opioids by women in the month before pregnancy or during the first trimester (25

2017 American College of Obstetricians and Gynecologists

136. Bupivacaine vs. Pethidine in Spinal Anesthesia of Old Patients: Haemodynamic Changes and Complications. (Abstract)

ischemia is vital. Various types of opioid analgesics have been used in order to pain control in these patients. We decided to conduct the present study in order to compare the hemodynamic changes of the old patients who undergo lower limbs orthopedic surgeries by applying subarachnoid bupivacaine and meperidine (pethidine).Sixty-six patients older than 60 years included according to inclusion and exclusion criteria and randomly allocated into two same groups, Then in the fi rst group in the sitting

2019 Asian journal of anesthesiology Controlled trial quality: uncertain

137. Usage of Intravenous Lidocaine Infusion with Enhanced Recovery Pathway in Patients Scheduled for Open Radical Cystectomy: A Randomized Trial (Abstract)

%. Postoperative pain scores, rescue analgesic consumption, times to return of bowel sounds, first flatus, first defecation, resuming of regular diet, length of hospital stay, in-hospital complications, and patient satisfaction were recorded.Patients in the lidocaine group experienced significantly lower pain scores after surgery at 6 hours (P = 0.005) and 12 hours (P = 0.001) at rest, and in the first 18 hours during mobilization (P < 0.05), with less paracetamol (P = 0.04) and meperidine (P = 0.02

2019 EvidenceUpdates

138. Side Effect Rates of Opioids in Equianalgesic Doses Via Intravenous Patient-Controlled Analgesia: A Systematic Review and Network Meta-analysis (Abstract)

on the primary outcomes (side effects), with some exceptions. Buprenorphine had a significantly higher RR of nausea and vomiting, whereas fentanyl had a lower RR of nausea and vomiting. Nalbuphine, butorphanol, methadone, and pethidine/meperidine had a lower risk of pruritus. Respiratory depression was rare (22 of 2452 patients). Pethidine/meperidine, fentanyl, and oxymorphone caused significantly lower sedation scores. Tramadol caused significantly lower satisfaction scores, whereas oxycodone, alfentanil (...) , remifentanil, fentanyl, and pethidine/meperidine caused significantly higher satisfaction scores.The opiate chosen for treatment most likely has little effect on the incidence of pruritus and nausea/vomiting, although considerable differences exist in terms of better and worse opioids in the presented rankings. Larger differences between drugs were observed with regard to sedation and patient satisfaction, and choosing the appropriate opioid may help to improve PCA in this regard.

2019 EvidenceUpdates

139. Opioids for agitation in dementia. (Abstract)

Improvement Group Specialized Register, on 13 June 2014 using the terms: narcotic OR opioid OR opium OR morphine OR buprenorphine OR codeine OR dextromoramide OR diphenoxylate OR dipipanone OR dextropropoxyphene OR propoxyphene OR diamorphine OR dihydrocodeine OR alfentanil OR fentanyl OR remifentanil OR meptazinol OR methadone OR nalbuphine OR oxycodone OR papaveretum OR pentazocine OR meperidine OR pethidine OR phenazocine OR hydrocodone OR hydromorphone OR levorphanol OR oxymorphone OR butorphanol

2015 Cochrane

140. Eptifibatide Accord

compatibility of Eptifibatide Accord when administered through an intravenous line with atropine sulfate, dobutamine, heparin, lidocaine, meperidine, metoprolol, midazolam, morphine, nitroglycerin, tissue plasminogen activator, or verapamil, is considered acceptable as well. Eptifibatide Accord is packaged in Type I glass containers with butyl rubber stoppers. The Type I glass complies with Ph. Eur. requirements. The stopper complies with Ph. Eur. requirements and appropriate compatibility studies have been

2016 European Medicines Agency - EPARs

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