4. TEACHING POINTS: MEDICATIONS AND PAIN MANAGEMENT

EXERCISE 4.1

Purpose: To review management of side effects and complications from medications used to control pain and anxiety. How would you manage the following case scenarios of patients undergoing uterine aspiration?

  1. A patient states that last year they had an allergic reaction to the local anesthetic that the dentist used.
    • It is important to distinguish between allergic reaction, side effect, and toxicity.
    • Allergic reactions to -caines are extremely rare, and mostly occur from the preservative or epinephrine.
    • Allergic reactions include itching, hives, bronchospasm, and progression to anaphylactic shock.
    • In this case, the safest alternative may be to avoid local anesthetic.
    • Instead use saline (plain or bacteriostatic), which is slightly less effective than lidocaine (Chanrachakul 2001, Glanz 2001).
  2. A patient chooses to have IV pain management due to extreme anxiety. You administer midazolam 1 mg and fentanyl 100 mcg. As you dilate the cervix, the patient falls asleep and is not easily arousable. The oxygen saturation falls from 99% to 88%.
    1. Both medications cause sedation and respiratory depression. Individuals react differently due to interaction with other agents (e.g. alcohol) or genetic differences in metabolism.
    2. Prevention can be aided by using a stepwise approach to pain management.
      • Smaller doses for low weight patients.
      • Serial doses until adequate pain control is achieved.
      • Reversal using antagonists, in a stepwise and titrated fashion.
      02 Saturation Management
      95 –100% Continue monitoring
      90 – 94% Check monitor lead placement
      Advise deep breathing
      Head tilt – chin lift to protect airway
      89% or less Provide titrated reversal agents
      Head tilt – chin lift to protect airway
      Initiate oxygen
      PPV if inadequate spontaneous breathing
      Transfer if persistent
      • Hypoxic patients who have received both an opioid and a benzodiazepine should generally receive naloxone before flumazenil. Naloxone reverses both opioid sedation and respiratory depression. Flumazenil has not been shown to reliably reverse respiratory depression, and also carries seizure risk if the patient has benzodiazepine tolerance or a seizure disorder.
      • Monitoring is recommended for two hours after use of reversal agents, because the sedative may last longer than the antagonist (ASA 2002).
  3. A patient who is 5 weeks by LMP has a history of alcohol and heroin abuse, and states that they “shot up” yesterday. The patient wants all the pain medication possible for the abortion procedure. Venous access is limited, but you finally succeed in inserting an IV, and administer midazolam 1 mg and fentanyl 100 mcg. You insert the speculum, and the patient complains that “I can feel everything” and “I need more meds.”  Return to Exercises
    1. How would you treat this pain? What do you need to take into consideration for patients with opioid tolerance?
      • Patients with opioid tolerance often require higher doses of medication to achieve pain control. A reasonable starting place for someone with significant tolerance would be to double the starting dose of fentanyl.
      • Keep in mind that intoxication can interfere with informed consent, warranting a delay in the procedure or LARC placement.
      • Rapid reversal of opiates or benzodiazepines in chronic users can also provoke withdrawal or seizures respectively.
      • Remember to utilize non-opioid forms of pain control and relaxation.
    2. How would this change if the patient were on suboxone?
      • Individuals on OMT or on chronic pain medications will also raise specific management issues such as caution with use of other meds (benzodiazepines), in addition to higher tolerance of opioids.
      • Those who are prescribed OMT or chronic opioids should continue taking their medications as prescribed.
      • If possible, communicate with their prescriber to plan for the procedure and follow-up or provide a note for patient regarding medications used.
      • Increase opioid dose as needed, guided by monitoring, reported pain, alertness, and respiratory rate.
      • Encourage the patient to have close follow-up with their prescribing physician.

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EXERCISE 4.2

Purpose: To become familiar with other medications used with uterine aspiration.
Please answer the following questions.

  1. In which of the following situations is administration of Rh-D immunoglobulin (Rhogam) suggested?
    1. Patient has positive anti-D antibody titre.
      • The patient may already be sensitized (in which case RhoGam will not help).
      • Or the patient recently received RhoGam and still has those anti-D antibodies in their blood (t ½ is 24 days).
      • In either case, don’t give RhoGam unless there is a new indication and 3 weeks have elapsed since the last dose.
    2. Rh-negative patient received RhoGam 4 weeks ago during evaluation for threatened abortion.
      • RhoGam may be present for up to 9-12 weeks after full-dose administration (Bichler 2003), but the manufacturer advises that it be given if three or more weeks have elapsed since the initial injection in term pregnancies.
      • Until further data delineates therapeutic levels after mini-dose RhoGam, re-dosing after 3 elapsed weeks may be prudent.
    3. Rh-negative patient is 4 days post-abortion and did not receive RhoGam at the uterine aspiration visit.
      • RhoGam should ideally be administered within 72 hours.
      • Beyond 72 hours, some recommend anti-D still be given as soon as possible, for up to 28 days (Fung Kee Fung 2003).
      • For medication abortion, RhoGam is ideally given at the time of mifepristone, but many give it up to 72 hours afterwards.
  2. While completing an early uterine aspiration procedure using local cervical anesthesia only, the patient complains of nausea and “feeling faint”. The patient is pale and sweating. The blood pressure is 90/50 with a pulse of 48.
    1. What is the differential diagnosis?
      • This appears to be a classic vasovagal reaction, with low pulse, hypotension, and sweating. Vasovagal reflex is caused by stimulation of the parasympathetic nervous system, and occurs often with cervical dilation, fear and other emotions. A patient who is overheated, dehydrated, hypoglycemic, or over-medicated may also be predisposed to syncope.
      • Differential Diagnosis: Vasovagal, hemorrhage, low blood sugar, or an inadvertent intravascular –caine injection.
      Vasovagal Reflex Hemorrhage Low Blood Sugar Intravascular -caine
      Slow pulse (< 50)
      Low BP
      Pallor
      Cool clammy skin
      +/- N/V
      +/- Abdominal Cramps
      Rare:  Syncope, Seizure-like activity
      Not orthostatic
      Rapid Pulse
      Late low BP
      Pallor, Cool clammy skin
      +/- N/V
      +/- Uterine cramps
      Rare:  Syncope
      Becomes orthostatic
      Normal / late rapid
      Late low BP
      Pallor, Cool clammy skin
      +/- N/V
      +/- Abdominal Cramps
      Rare:  Syncope, Seizures
      Not orthostatic
      Slow pulse (<50)
      Tinnitus
      Perioral tingling
      Metallic taste
      Irregular pulse
      Rare: seizure,
      ventricular arrhythmias,
      cardiac arrest
      Not orthostatic
    2. How might you prevent this reaction?
      • To help prevent vasovagal reactions, emphasize hydration, keeping cool (i.e. walking to clinic during warm weather), and staying calm. Isometric extremity contractions may also help prevent vasovagal (see below).
    3. How would you manage this patient?
      • Vasovagal Management
        • Airway / Positioning: supine or Trendelenburg, head to side if vomiting
        • Cool cloth on head or neck
        • Sniffing ammonia capsule may help
        • Vasovagal reflex may be aborted prior to syncope by isometric contractions of the extremities (gripping the arm, hand, leg and foot muscles) (Cason 2014). These maneuvers activate the skeletal-muscle pump to augment venous return and abort the reflex.
        • Prolonged vasovagal, consider:
          • Atropine
          • IV Fluids, oxygen
          • Evaluation for other potential causes (hemorrhage, etc.)
          • Record events, and transfer as needed.

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