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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

123. 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

124. Practice Guidelines for Moderate Procedural Sedation and Analgesia

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

125. 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

128. 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

130. Management of Spontaneous Labour at Term in Healthy Women

options in labour. These may include pharmacological and non-pharmacological measures. (III-A) 9. Each woman should be provided with evidence-based information about labour analgesia options prior to the onset of labour and offered ample opportunity to discuss the risks and benefits of each option available at her planned site of delivery. (III-A) 10. The use of meperidine as labour analgesia should be avoided due to its long-acting active metabolites and negative effects on neonatal behaviours. (II

2016 Society of Obstetricians and Gynaecologists of Canada

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)

135. 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. Nitrous Oxide Use for Labor Pain Management

of women using 50% N2O/50% oxygen to epidural anesthesia. It found that 7% of the N2O group had Apgar scores less than or equal to seven at one minute after birth compared to 6% of infants of women who used epidurals. At five minutes, the proportions with low Apgar scores were 1% and 4%, respectively (p values not reported). There was a statistically significant finding in one study of lower arterial cord blood gasses among infants of primiparous women who used N2O plus meperidine (a parenteral opioid (...) ) compared to those who used an epidural (pH 7.21 vs. pH 7.29, p<0.01). Use of meperidine alone has been associated with lower umbilical cord gasses and so it is not clear whether this finding can be attributed to N2O use or only to use of meperidine. The AHRQ SR was unable to analyze neonatal intensive care unit admission because of the varying definitions of intensive care across countries and lack of reporting of this outcome. Only one study included in the AHRQ SR compared neonatal neurobehavioral

2016 Oregon Health Evidence Review Commission

137. Management of Spontaneous Labour at Term in Healthy Women

caregivers. (III-A) 8. When appropriate, health care providers should support women in their choice of analgesic options in labour. These may include pharmacological and non-pharmacological measures. (III-A) 9. Each woman should be provided with evidence-based information about labour analgesia options prior to the onset of labour and offered ample opportunity to discuss the risks and benefits of each option available at her planned site of delivery. (III-A) 10. The use of meperidine as labour analgesia

2016 Society of Obstetricians and Gynaecologists of Canada

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

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

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

%. 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

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