Page 117 Complete Your CE Test Online - Click Here Risk factors for respiratory depression in patients on opioid therapy include the following (Jarzyna et al., 2011; Pasero, Quin, Portenoy, McCaffery, & Rizo, 2011): ● ● Age > 55 years. ● ● Pulmonary disease, such as COPD. ● ● Known or suspected sleep apnea. ● ● Airway abnormalities. ● ● Systemic disease. ● ● Renal or hepatic disease. ● ● Smoking. ● ● A history of opioid-induced respiratory depression. ● ● Obesity. ● ● Opioid naïve but required high dosages of pain medication in PACU. ● ● Patient receiving PCA with basal rate. ● ● Incisions that may interfere with ventilation. ● ● Patient taking other medications with sedative properties. Adjuvant medications Adjuvant medications are medications not typically used for pain relief but may be helpful in certain pain-causing conditions with or without the presence of a pain reliever. Adjuvant medications include antidepressants, anticonvulsants, and botulinum toxins. Antidepressants can be useful for patients with chronic pain conditions even if they do not suffer from depression (ACPA, 2016). They tend to work better for patients experiencing certain types of pain, such as those from fibromyalgia, headache, and neuropathy as opposed to pain that is acute or musculoskeletal in nature (ACPA, 2016). Anticonvulsant medications, such as gabapentin and carbamazepine, have been useful in certain chronic pain conditions that involve nerve injury (ACPA, 2016). Other medications that may be used in patients experiencing pain include botulinum toxins to decrease hypertonic muscles, medical marijuana, topical anesthetics, and muscle relaxants (ACPA, 2016). Nursing consideration: All medications have side effects and potential interaction with other medications and must be considered carefully for each individual experiencing pain. Interventional pain relief treatments Interventional pain relief treatments include various types of nerve blocks, injections, and spinal cord stimulation. Neuraxial analgesia Neuraxial analgesia includes spinal, epidural, and combined spinal- epidural analgesia (Silva & Halpern, 2010). Epidural analgesia is the use of local anesthetics and adjuvant medications injected into the epidural region of the spine. Spinal anesthesia is the injection of local anesthetics (with or without the use of adjuvant medication) into the subarachnoid space (Silva & Halpern). Combined spinal-epidural analgesia is analgesia that starts with an intrathecal injection and the placement of an epidural catheter for delivery of an additional drug (Silva & Halpern). Neuraxial anesthesia is the most effective and most commonly used pain reliever utilized in women in childbirth (D’Arby Toledano & Leffert, 2017). Various medications are used in neuraxial anesthesia but typically include local anesthetics and opioids. Epidural steroid injections Epidural steroid injections (ESIs) are the most commonly used pain management procedures worldwide (Cohen, Bicket, Jamison, Wilkinson, & Rathmell, 2013). ESIs are used to treat neck and back pain and radiating pain in the arms and legs (FDA, 2016). A variety of medications is used, including local anesthetics and glucocorticoids (Ter Meulen et al., 2017). Injectable corticosteroids, injected into the epidural space, are used to treat inflammation. Even though they have been used for decades, they are not approved by the FDA for this use (FDA, 2014). Rarely, complications from ESIs include loss of vision, stroke, paralysis, and death (FDA). Lumbar and cervical dural punctures during the procedure can result in significant neurological injury (Epstein, 2017). Nursing consideration: The use of injectable corticosteroids into the epidural region of the spine can cause rare, but severe, neurological side effects (FDA, 2014). Nurses should ensure the patient knows to report any side effects immediately, such as loss of vision or changes in vision, tingling or weakness in extremities or face, dizziness, severe headache, or seizures (FDA, 2014). Peripheral nerve blocks Peripheral nerve blocks (PNBs) deliver local anesthesia via a catheter placed near the nerve. Nerve blocks can be a single injection lasting up to 24 hours or continuous and lasting longer for those requiring pain relief for an extended. They are managed in an outpatient setting (Jeng & Rosenblatt, 2017). PNBs can be useful in patients with acute and severe pain that is not managed with systemic medications, in outpatients who require long-acting or continuous PNBs, in patients with an intolerance to opioids, or in patients at risk for respiratory depression from opioids (Jeng & Rosenblatt, 2017). PNBs are also useful in situations where general anesthesia is undesirable and for operative anesthesia or for postoperative pain control (Falk & Fleisher, 2017). And they are effective at minimizing the use of opioids (Jeng & Rosenblatt). PNBs are placed by either ultrasound-guided technique or nerve stimulator guidance in which a stimulator needle stimulates the desired nerve with electrical current until maximum motor response is reached and desired location of the block is achieved (Jeng & Rosenblatt, 2017). Patient-controlled analgesia Patient-controlled analgesia (PCA) is a form of pain control under the control of the patient and is useful for on-demand pain relief directed by the patient. PCA is intravenously delivered opioid medication that can be accessed via a button given to the patient. It can have a background or basal rate of infusion in addition to on-demand doses (Grass, 2005). PCA consists of an initial loading dose, demand dose, and one- and four-hour limits as set by the prescriber (Grass, 2005). Patients who are older and those with kidney dysfunction, respiratory disease, or on sedating medication should be monitored closely if using PCA (Marks & Rodgers, 2014). Multimodal approach to pain management A multimodal approach to pain management involves the administration of two or more drugs that provide analgesia via different mechanisms. The route of administration can be the same or different (American Society of Anesthesiologists, 2012). Multimodal pain management can include central regional blockade with local anesthetics, COXIBs, NSAIDS, or acetaminophen (American Society of Anesthesiologists).