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Journal Course Evidence Based Use of Nonopioid Analgesics August 2018
Journal Course Evidence Based Use of Nonopioid Analgesics August 2018
course of long-term opioid treatment. Peripherally acting ing effect, presumably due, at least in part, to the lack of a
µ opioid receptor antagonists, including methylnaltrex- first-pass liver effect.22 The side effects of acetaminophen
one, naloxegol, and alvimopan improve bowel symptoms can include allergic reaction and liver toxicity. Indeed,
without compromising opioid analgesic effects. The poten- it is important to inform the patient and postoperative
tial side effects of these drugs include abdominal pain.18 care team members of acetaminophen administration, to
Dose-dependent increases in biliary duct pressure and prevent overdose.
sphincter of Oddi tone are produced by opioid receptor- Ketamine is a dissociative anesthetic agent with pro-
mediated mechanisms. Opioids also increase urinary found analgesic effects due to noncompetitive inhibi-
sphincter tone.2 tion of N-methyl-d-aspartate receptors in the CNS.23
Although opioids blunt the surgical stress response, Ketamine use for nonopioid analgesia has been revived
these drugs also have immunosuppressant effects. in recent years because of the drug’s efficacy and lack
Opioids inhibit natural killer cell function and stimu- of opioid-related side effects, and its utility when used
late cancer cell proliferation because of their effects on for opioid-dependent chronic pain patients.24 Ketamine
angiogenesis and tumor cell signaling pathways.19 Use doses for analgesia vary depending on the patient and
of nonopioid analgesics may help offset these risks in clinical situation, and in one clinical investigation of
scenarios involving immunocompromise or cancer. opioid-dependent patients undergoing back surgery,
patients received 0.5 mg/kg of ketamine on induction,
Nonopioid Mechanisms of Analgesia followed by an infusion of 10 μg/kg/min started before
The Certified Registered Nurse Anesthetist (CRNA) has a incision and terminated on skin closure.24 Patients who
robust arsenal of nonopioid analgesic drugs from which received ketamine required 37% less morphine and re-
to choose, depending on the individual patient’s history ported less pain at 6-week postoperative follow-up. Side
and needs (Table 2). Acetaminophen is a well-character- effects include increased oral secretions, tachycardia and
ized nonopioid analgesic drug, often chosen because of hypertension, vivid and unpleasant dreams, and increas-
its benign effect on gastric mucosa and platelet function, es in intracranial pressure.
although it is known to have no ameliorating effect on Dexamethasone is a glucocorticoid steroid drug,
inflammation.20 The exact mechanism of action of ac- which is a fluorinated derivative of prednisolone.23 Used
etaminophen remains unclear, although some investiga- traditionally for its anti-inflammatory effects on such
tions have suggested the drug has a weak effect on cyclo- conditions as airway inflammation and cerebral edema,
oxygenase 1 (COX-1) and COX-2 gene expression. The this glucocorticoid drug is being increasingly used for its
IV form of acetaminophen, marketed as Ofirmev, is given systemic analgesic effect23,25 and for its ability to prolong
over 30 minutes at a dose of 1,000 mg every 6 hours for peripheral neural blockade when administered parenter-
children and adults weighing more than 50 kg, and 15 ally or as a component of the local anesthetic solution.26
mg/kg every 6 hours for children 2 to 12 years of age Doses vary widely depending on the intended effect,
and adults and adolescents weighing less than 50 kg.21 route of administration, and clinical situation, with 8 mg
Clinical investigation has shown the parenteral form of intravenously having been reported to have a systemic
acetaminophen to have a powerful analgesic opioid-spar- analgesic effect, and a similar dose combined with local
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