Opioid Analgesics
Class Summary
Induction of anesthesia is accomplished by using high doses of opioid. Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties that are beneficial for patients who experience pain.
Morphine sulfate (Duramorph, Astramorph, MS Contin, Avinza, Kadian)
Morphine sulfate is the DOC for analgesia owing to its reliable and predictable effects, safety profile, and ease of reversibility with naloxone.
Various IV doses are used; it is commonly titrated until the desired effect is obtained.
Nonsteroidal Anti-inflammatory Drugs
Class Summary
NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. Their mechanisms of action are unknown, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may be present, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.
Naproxen (Anaprox, Naprelan, Aleve, Naprosyn)
Naproxen is used for relief of mild to moderate pain; it inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, which is responsible for prostaglandin synthesis.
Ibuprofen (Motrin, Advil, Addaprin, Caldolor )
Ibuprofen is the drug of choice for mild to moderate pain. It inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis. Many doses are available, either with or without a prescription.
Ketoprofen
Ketoprofen is used for the relief of mild to moderate pain and inflammation. Small doses are indicated initially in patients with small body size, elderly patients, and persons with renal or liver disease. Doses of over 75 mg do not increase therapeutic effects. Administer high doses with caution, and closely observe the patient for response.
Flurbiprofen
Flurbiprofen may inhibit cyclooxygenase, thereby inhibiting prostaglandin biosynthesis. These effects may result in analgesic, antipyretic, and anti-inflammatory activities.
Diclofenac (Voltaren XR, Cataflam, Cambia)
This is one of a series of phenylacetic acids that has demonstrated anti-inflammatory and analgesic properties in pharmacological studies. It is believed to inhibit the enzyme cyclooxygenase, which is essential in the biosynthesis of prostaglandins. Diclofenac can cause hepatotoxicity; hence, liver enzymes should be monitored in the first 8 weeks of treatment. It is absorbed rapidly; metabolism occurs in the liver by demethylation, deacetylation, and glucuronide conjugation. The delayed-release, enteric-coated form is diclofenac sodium, and the immediate-release form is diclofenac potassium.
Tolmetin
Tolmetin inhibits prostaglandin synthesis by decreasing the activity of the enzyme cyclooxygenase, which in turn decreases formation of prostaglandin precursors. The pediatric dosage is 20 mg/kg/d PO divided tid/qid initially, then 15-30 mg/kg/d, not to exceed 30 mg/kg/d.
Celecoxib (Celebrex)
Celecoxib inhibits primarily COX-2. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited; thus, incidence of GI toxicity, such as endoscopic peptic ulcers, bleeding ulcers, perforations, and obstructions, may be decreased when compared with nonselective NSAIDs.
Seek the lowest dose for each patient. The adult dosage is 100-200 mg PO bid; the pediatric dosage (which has not been established for patients younger than 2 years) is 50 mg PO bid for patients 2 years or older whose weight is ≥10 kg to ≤25 kg, and is 100 mg PO bid for patients 2 years or older whose weight is >25 kg.
Indomethacin (Indocin)
Indomethacin is used for relief of mild to moderate pain; it inhibits inflammatory reactions and pain by decreasing the activity of COX, which results in a decrease of prostaglandin synthesis.
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Typical appearance of (A) teenaged boy with severe pectus excavatum and (B) young girl with pectus deformity.
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Nuss procedure. Appearance of chest before (above) and after (below) Nuss operation for pectus excavatum. Image illustrates cosmetic advantage of minimally invasive approach.
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Noncontrast chest CT scan of patient with pectus excavatum. Chest Haller index is ratio of lateral (transverse) diameter of chest wall to anteroposterior diameter at point of maximal depression of sternum.
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Young infant with pectus excavatum.
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Nuss procedure. Range of pectus bar sizes available (7-17 in.).
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Nuss procedure. Technique for bending pectus bar on back table.
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Nuss procedure. Minimally invasive technique for correction of pectus excavatum (3) with thoracoscopy (1). Note long clamp passed from one side to other (2) to grab umbilical tape (4), which serves to guide passage of pectus bar behind sternum.
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Nuss procedure. Pectus bar after being passed behind sternum (5), under thoracoscopic visualization (1), and before being turned over. Note that concavity of bar is facing up.
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Nuss procedure. Pectus bar passed behind sternum before and after being turned over. Inset shows proper technique for fixation of pectus bar against lateral chest wall musculature.
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Nuss procedure. Thoracoscopic images at time of minimally invasive repair. (A) Pectus bar passer behind sternum and next to mediastinum and pericardial sac. (B) Umbilical tape being passed across anterior mediastinal space. (C) Bar being passed across anterior mediastinal space (anterior to heart). (D) Pectus bar flipped and resting under sternum. (E) Third point of fixation of pectus bar.
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Nuss procedure. Position of pectus bar in relation to ribs and sternum, as well as location of third point of fixation.
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Nuss procedure. Chest radiograph of 17-year old male with Marfan syndrome and severe pectus excavatum, in whom it was necessary to place two pectus bars.
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Patient with pouter pigeon breast. Note protrusion of manubriosternal junction and adjacent costal cartilages with S-shaped appearance of sternum.
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Nuss procedure. Pectus bar being pulled out of chest with bone hook instrument.
