PAIN DRUGS HANDBOOK TABLE
OF CONTENTS
About the
Author
About
the Handbook
Acknowledgments
Forward
to 2rd Edition
Forward
to 1st Edition
DRUGS (Alphabetical Order)
TOPICAL AGENTS
Amitriptyline
Baclofen
Clonidine
Cyclobenzaprine
2-deoxy-d-glucose
Dexamethasone
Dextromethorphan
Diclofenac
Doxepin
DMSO
Gabapentin
Ketamine
Ketoprofen
NEUROLYTIC AGENT
Phenol
APPENDICES
Appendix 1: World Health Organization
Three-step Ladder
Appendix 2: Drug Tables
Appendix 3: Infusion Tables
Appendix 4: Relative Potencies of
Opioids Effects
Appendix 5: Relative Potencies of Steroids
Appendix 6: Intravenous PCA
Standard Orders
Appendix 7: Patient Controlled Analgesia Flow Sheet
Appendix 8: Relative Potencies of Opioids
Appendix 9: Epidural Analgesia Monitoring Orders
Appendix 10: Pain Rating Scales
Appendix 11: Multiplication Factors for Converting the
Daily Dose of a Prior Opioid to the Daily Dose of Oxycontin
Appendix 12: CPR Algorithms
Appendix 13: Pediatric CPR Algorithms
Appendix 14: Trade Name Table
BIBLIOGRAPHY
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Sota
Omoigui's
Pain Drug Handbook
2nd Edition:
Sufentanil
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SECTION
ONE:
Class,
Uses, Dosing,
Elimination
SECTION TWO:
Preparation, Pharmacology, Pharmacokinetics
SECTION THREE:
Interactions, Toxicity
Guidelines/Precautions
Principal Adverse Reactions
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Class
(NARCOTIC AGONIST)
Uses
treatment of acute, chronic and cancer pain
Dosing
Pain: IV/IM 10-30 mcg (0.2-0.6 mcg/kg)
Intranasal 1.5-3 mcg/kg. Use undiluted injectate solution for intranasal route.
Epidural: bolus 10-50 mcg (0.2-1 mcg/kg)
infusion 5-30 mcg/hour (0.1-0.6 mcg/kg/hr)
Spinal: 1-10 mcg (0.02-0.01 mcg/kg)
Patient Controlled Analgesia IV: bolus 2-10 mcg (0.04-0.2 mcg/kg)
infusion 2-20 mcg/hr (0.04-0.4 mcg/kg/hr)
Lockout Interval 3-10 minutes
Patient Controlled Analgesia Epidural: bolus 4-8 mcg (0.08-0.16 mcg/kg)
infusion 4-8 mcg/hr (0.08-0.16 mcg/kg/hr)
Lockout Interval 10-20 minutes
Due to impaired elimination, accumulation and excess sedation may occur in patients with hepatic dysfunction. Analgesia may be enhanced by addition of adjuvant drugs e.g. NSAIDs, antidepressant agents (see front matter for drug combinations) and use of non-drug therapies e.g. TENS.
Elimination
hepatic
Preparation
Sufentanil Citrate (Sufenta)
Injection: 50 mcg/ml
DILUTION FOR INFUSION: IV: 500 mcg in 100 mls NS (5 mcg/ml)
Epidural bolus: 10-30 mcg in 15-20 mls local anesthetic or (preservative free) NS.
infusion: 100 mcg in 100 mls local anesthetic or (preservative free) NS. (1 mcg/ml).
Pharmacology
A potent narcotic, sufentanil is a thiamyl analog of fentanyl with 5-7 times the parenteral analgesic potency and 2-5 times the epidural/intrathecal analgesic potency. Compared with fentanyl, sufentanil has a shorter duration of action. Cardiovascular effects of both drugs are generally similar. Sufentanil may produce a dose dependent bradycardia probably by stimulation of the vagal nucleus in the medulla. Depression of ventilation is due to a decrease in response of the respiratory centers in the brain stem to increases in CO2. Sufentanil (and fentanyl) are more lipophilic than morphine and segmentation of epidural analgesia reflects rapid vascular uptake as well as incorporation in the lipid structures of the spinal space (epidural fat and white matter). The segmental limitation of analgesia requires placement of the epidural catheter at sites adjacent to the dermatomes to be covered. Large volumes of diluent may enable more dermatomes to be included. Sufentanil crosses the placental barrier and may produce depression in the neonate. The drug may appear in breast milk and should be used with caution in nursing mothers.
Pharmacokinetics
ONSET OF ACTION: IV 1-3 minutes Intranasal < 5 minutes
Epidural/Spinal 4-10 minutes
PEAK EFFECT: IV 3-5 minutes Intranasal 10 minutes
Epidural/Spinal <30 minutes
DURATION OF ACTION: IV 20-45 minutes IM 2-4 hours
Epidural/Spinal 2-4 hours
Interactions
circulatory and ventilatory depressant effects potentiated by other narcotics, sedatives, nitrous oxide, volatile anesthetics; ventilatory depressant effects potentiated by MAO inhibitors, phenothiazines and tricyclic antidepressants; analgesia enhanced and prolonged by alpha-2 agonists (e.g. clonidine, epinephrine); addition of epinephrine to intrathecal/epidural sufentanil results in increased side effects (e.g. nausea) and prolonged motor block. skeletal muscle rigidity in higher dosages sufficient to interfere with ventilation; increased incidences of bradycardia with use of vecuronium.
Toxicity
Toxic Range:
Not routinely monitored
Manifestations:
Somnolence
Coma
Respiratory Arrest
Apnea
Cardiac Arrhythmias
Combined respiratory and metabolic acidosis
Circulatory Collapse
Cardiac Arrest
Death
Antidote:
Naloxone 0.4-2 mg IV/IM/SC. Repeat dose every 2 to 3 minutes to a maximum of 10-20 mg.
Management:
Discontinue or reduce medication
Support ventilation and circulation (Patent Airway, Oxygen, IV Fluids, Vasopressors)
Administer antidote
Monitor blood gases, pH and electrolytes
Correct acidosis and electrolyte disturbance (lactic acidosis may require IV sodium bicarbonate 1-2 mEq/kg)
Symptomatic treatment
Airway protected - ipecac syrup induced emesis (30 mls or 0.5 mls/kg ipecac syrup followed by 200 mls or 4 mls/kg of water or clear fluid) or gastric lavage (with drug ingestion) followed by administration of activated charcoal (PO 50-100 grams or 1-2 gram/kg)
Guidelines
(1) Reduce doses in elderly, hypovolemic, high risk surgical patients and with concomitant use of sedatives and other narcotics. Incremental doses should be determined from effect of initial dose.
(2) Narcotic effect reversed with naloxone (0.2-0.4 mg IV or higher). Duration of reversal may be shorter than duration of
narcotic effect.
(3) Sufentanil may produce a dose-related rigidity of skeletal muscles
(4) The drug crosses the placental barrier and usage in labor may produce depression of respiration in the neonate. Resuscitation may be required; have naloxone available.
(5) Undesirable side effects of epidural, caudal or intrathecal sufentanil include delayed respiratory depression ( up to 8 hours) , pruritus, nausea and vomiting, urinary retention. Naloxone (0.2-0.4 mg IV prn or infusion 5 -10 mcg/kg/hr) is effective for prophylaxis and/or treatment. Ventilatory support for respiratory depression must be readily available. Antihistamines e.g. diphenhydramine (12.5-25 mg IV/IM q 6 hour prn) may be used in treating pruritus. Metoclopramide (10 mg IV q 6 hour prn), may be used in treating nausea and vomiting. Urinary retention that does not respond to naloxone may require straight bladder catheterization. Betanechol (Urecholine) PO 15-30 mg tid or SC 2.5-5 mg three or four times daily as required may be used as an alternative to naloxone (betanechol increases the tone of the detrusor urinae muscle. It should not be given IV or IM, which may result in cholinergic overstimulation. Have atropine available [IV/SC 0.5 mg])
(6) Epidural, caudal or intrathecal injections should be avoided when the patient has septicemia, infection at the injection site or coagulopathy.
(7) Patients should be warned that sufentanil may impair their ability to perform hazardous tasks requiring mental alertness or physical coordination (e.g. driving a motor vehicle, operating heavy machinery).
(8) Sufentanil is subject to control under the Federal Controlled Substances Act of 1970 as a schedule II (C-II) drug.
Adverse
CVS: hypotension, bradycardia.
PULM: respiratory depression, apnea
CNS: dizziness, sedation, euphoria, dysphoria, anxiety
GI: nausea, vomiting, delayed gastric emptying, biliary tract spasm
EYE: miosis
MUSCULOSKELETAL: muscle rigidity
Reactions
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Toll-Free: (800) 9-MEDIC-9, Phone: (310) 675-9121,
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NOTICE:
Every effort has been made to ensure that the drug dosage schedules
herein are accurate and in accord with the standards accepted
at the time of publication. As new research and experience broaden
our knowledge, changes in treatment and drug therapy occur. The
medications described do not necessarily have specific approval
by the Food and Drug Administration for use in the situations
and the dosages for which they are recommended. This information
is advisory only. The package insert should be consulted for use
and dosage as approved by the FDA, for any changes in indications
and dosages and for added warnings and precautions. The ultimate
responsibility lies with the prescribing physician.
No part of this information may be reproduced or transmitted electronically
in any information storage or retrieval system, or within any
monitoring system without prior permission in writing from S.O.T.A.
Technologies (Electronic Publishers).
The Universal Drug Infusion Slide Ruler (patent pending) is now
available. It incorporates an infusion data guide and enables
infusion calculations for any drug at any dose and at any concentration.
It may be obtained by calling S.O.T.A Technologies (800 9-MEDIC-9)
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