Morphine & emergency department

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  Morphine and the Emergency Department
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  • 1.  Cheryl Hunter Lamar University November 12, 2015
  • 2. Drugs o 212.1 million drugs prescribed in the ED in 2008 o Analgesics most prescribed drug class in ED in 2011(Center for Disease Control and Prevention [CDC], 2011, table 2). • Morphine is the standard (Wenderworth, Kaneda, Amini, Amini, & Patanwala, 2013). • 8% of patients in the ED receive at least one dose! (Wenderworth et al., 2013). http://www.theguardian.com/science/2007/aug/04/sciencenews
  • 3. Pain o Accounts for 78% of emergency room visits(Todd et al., 2007). o Complex and difficult to define o Varied etiology (Belden, DeFriez, & Huether, 2012). http://www.doctorramey.com/the-pain-that-is-back-pain-part- one/
  • 4. Pharmacodynamics o Pure opioid agonist o Mimics action of opioid peptides to bind with mu receptors in pain centers of the CNS and spinal cord • Produces analgesic effect (Foy & Peterson, 2013; Lehne, 2013). o Effective pain reliever • Best for severe, chronic, dull pain • Generally lowers pain 2 points on pain scale (Wenderworth et al., 2013) • Pain more tolerable and less distressing • Reduces anxiety • Creates sense of well-being (Lehne, 2013)
  • 5. Potential Drug Interactions o Alcohol o Antihistamines o Benzodiazepines o Antidepressants o Phenothiazines o Antihypertensives o Opioid agonists o Agonist-antagonist opioid (Lehne, 2013). http://www.fierceemr.com/story/analysis-doc-notes-ehrs-can-flag-drug-interactions/2013-04- 11
  • 6. Adverse Effects o Urinary Retention o Constipation o Respiratory distress o Orthostatic hypotension o Tolerance & Dependence o Nausea & Vomiting o Itching o Dizziness o Drowsiness o Dysphoria (Foy & Peterson, 2013; Lehne, 2013; Miller, Schauer, Ganem, & Bebarta, 2015).
  • 7. Pharmacokinetics o Administration routes • PO, Rectal, IV, IM, intrathecal or intraspinal o Distribution • Throughout the body • Limited lipid solubility • Small amounts cross blood brain barrier o Metabolism • Almost completely in the liver • Three hour half-life • PO administration subject to first-pass effect • Requires higher doses o Absorption • GI tract o Excretion • Renal (Foy & Peterson, 2013; Lehne, 2013) http://www.thetruthaboutforensicscience.com/pharmacology-part-2- pharmacokinetics/
  • 8. Pharmacogenomics o Variations to the mu opioid receptor gene • Changes in pharmacodynamics and pharmacokinetics • 118G allele require higher doses than 118A allele • G genotype have decreased analgesic response (Sia et al., 2013) o Variations to CYP2D6 • Determine rate of metabolism • Poor metabolizers • Intermediary metabolizers • Extensive metabolizers • Ultra-rapid metabolizers • (Chummun, 2011; Sia et al., 2013; Wu & Kearney, 2013). http://www.brunswick.k12.me.us/bhslibrary/genetics-research-ms-kirk/
  • 9. Binding Interactions o Naloxone (Narcan) • Pure opioid antagonist • Structurally comparable to morphine • Competes or blocks morphine at opioid receptors • Reduces pharmacological effects • IV,IM or Sub Q • Hepatic metabolism • Two hour half-life • Rapid first-pass effect makes PO route ineffective (Foy & Peterson, 2013; Lehne, 2013).
  • 10. Interprofessional Team Communication and Patient Safety o Morphine Order Sets • Developed by interprofessional team • Physicians • Nurses • Pharmacists • Increase safety in ordering and administration o Incident Reporting • Adverse drug reactions • Sentinel events • Best practice improvements http://certification.acsm.org/blog/2013/may/interprofessional- competencies-in-healthcare-four-core-domains
  • 11. Conclusion o The benefits of understanding the pharmacodynamics, pharmacokinetics and pharmacogenomics of Morphine. . . • Assessment • Signs and symptoms • Adverse reactions r/t morphine administration and disease process • Drug interactions • Efficacy • Drug toxicity • Genetic Variation • Rate of metabolism • Practice • Patient Advocate • effective • Safe, competent care
  • 12.  Belden, J., DeFriez, C., & Huether, S. E. (2012). Pain, temperature, sleep and sensory function. In S. E. Huether & K. L. McCance (Eds.), Understanding pathophysiology (5th ed., pp. 324-345). St. Louis, MO: Elsevier.  Center for Disease Control and Prevention. (2011). National hospital ambulatory medical care survey: 2011 emergency department summary tables [Report]. Retrieved from http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2011_ed_web_tables.pdf  Chummun, H. (2011). Understanding pharmacogenomics: Applications in prescribing. Nurse Prescribing, 9(8), 402-407. Retrieved from http://www.nurseprescribing.com/  Forero, R., Mohsin, M., McCarthy, S., Young, L., Leraci, S., Hillman, K., ... Phung, H. (2008). Prevalence of morphine use and time to initial analgesia in an Australian emergency department. Emergency Medicine Australasia, 20, 136-143. http://dx.doi.org/10.1111/j.1742-6723.2008.01068.x  Foy, M., & Peterson, A. M. (2013). Principles of pharmacology in pain management. In V. P. Arcangelo & A. M. Peterson (Eds.), Pharmacotherapeutics for advanced practice (3rd ed., pp. 79-95). Ambler, PA: Lippincott Williams & Wilkins.  Lehne, R. A. (2013). Pharmacology for nursing care (8th ed.). St. Louis, MO: Elsevier.  Miller, J. P., Schauer, S. G., Ganem, V. J., & Bebarta, V. S. (2015). Low-dose ketamine vs morphine for acute pain in the ED: A randomized controlled trial. American Journal of Emergency Medicine, 33, 402-408. http://dx.doi.org/10.1016/j.ajem.2014.12.058  Peterson, A. M. (2013). Pharmacokinetic basis of therapeutics and pharmacodynamic principles. In V. P. Arcangelo & A. M. Peterson (Eds.), Pharmacotherapeutics for advanced practice (3rd ed., pp. 15-29). Ambler, PA: Lippincott Williams & Wilkins.  Sia, A. T., Lim, Y., Lim, E. C., Ocampo, C. E., Lim, W., Cheong, P., & Tan, E. (2013). Influence of mu-opioid receptor variant on morphine use and self-rated pain following abdominal hysterectomy. The Journal of Pain, 14(10), 1045-1052. http://dx.doi.org/10.1016/j.jpain.2013.03.008  Wenderworth, B. R., Kaneda, E. T., Amini, A., Amini, R., & Patanwala, A. E. (2013). Morphine versus Fentanyl for pain due to traumatic injury in the emergency department. Journal of Trauma Nursing, 20(1), 10-15. http://dx.doi.org/10.1097/JTN.Ob013e31828660b5  Wu, A. H., & Kearney, T. (2013). Lack of impairment due to confirmed codeine use prior to a motor vehicle accident: Role of pharmacogenomics. Journal of Forensic and Legal Medicine, 20, 1024-1027. http://dx.doi.org/10.1016/j.jflm.2013.09.019
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