APCblogit

Why not use Demerol for pain?

By Blaine Carmichael, MPAS, PA-C, DFAAPA

 One of the most widely used opioid analgesics, meperidine (Demerol) is rapidly falling out of favor. In spite of its FDA-labeled indication, there are many reasons why meperidine is not suitable for chronic pain. Repeated dosing with meperidine will cause an accumulation of the toxic metabolite normeperidine, especially of concern in patients with renal impairment. Normeperidine is a potent central nervous system irritant. Symptoms of normeperidine accumulation progress from irritability, to tremors and myoclonus, to generalized seizures. There is no benefit in using meperidine over other parenteral opioids for the treatment of common pain problems including biliary colic, pancreatitis, labor, and migraine.

IM injections of meperidine are painful and absorption is erratic. The oral dosage form should not be used due to high first pass liver metabolism and the ensuing increased concentration of normeperidine. Meperidine is seldom indicated for analgesia in children. It is inappropriate therapy for migraine headache. Do not use it in patients with renal insufficiency, untreated hypothyroidism, Addison's disease, benign prostatic hyperplasia, or urethral stricture. Meperidine should not be used for longer than 48 hours or at doses greater than 600 mg/24 hours in patients with normal renal function.

What are the side effects of meperidine? It can cause anxiety, fluctuations in awareness levels, hallucinations, agitation, delusions, disorientation, restlessness, bizarre feelings (eg, feeling frightened), seizures, diaphoresis, shakiness, myoclonic jerks, nervousness, tremors, and confusion.

In cases of normeperidine neurotoxicity, naloxone should not be used. Naloxone is effective in reversing episodes of nonseizure apnea induced by meperidine.

Use with extreme caution in patients with pre-existing convulsive disorders, and in patients receiving drugs that are known to predispose them to seizures (e.g., imipenem).

 

FURTHER READING

Chalverus, CA. Clinically significant meperidine toxicities.  J Pharm Care in Pain & Symptom Control 2001;9:37-55

Latta, KA, Ginsberg, B, Barkin, RL. Meperidine: A critical review. Am J Therapeutics. 2002;9:53-68

Great news about Advanced Trauma for Life Support course!

By Bob Blumm, PA-C

Beginning in October 2008 with the release of the 8th Advanced Trauma for Life Support (ATLS) course manual, “physician extenders”—including Advanced Practice Clinicians (APCs, nurse practitioners and physician assistants)—who complete the ATLS course will receive cards to document their participation. Published since 1980, the American College of Surgeons' ATLS course is taught in hospitals and institutions worldwide.

“The doctor who first attends to the patient has the greatest opportunity to impact outcome,” according to the ATLS Web site (http://www.facs.org/trauma/atls/information.html). Now APCs can be recognized as accredited providers of this critical care.

This change in philosophy is almost 15 years in the making. Five years ago the best we could hope for as nonphysicians was inclusion of 25% nonphysicians in the course, which teaches only 16 students at a time—and this was at the discretion of the regional trauma director. A letter would be given after completion of the entire ATLS program that the APC attended the course. We have repeatedly requested the same certifying card that is given to doctors. At last, the opposition has relented. APC’s are an important and integral member of the team and this recognition is long overdue.

Do you agree that certifying NPs and PAs is a great idea whose time has come? Will documentation that you have successfully completed the ATLS course positively affect your practice? Post a comment to tell us your thoughts about this important development.

Bob Blumm, an APCToday Editorial Board Member, is an instructor for the Trauma Evaluation And Management (TEAM) course, a program for medical students and NPs and PAs in emergency trauma departments. This is a preparatory program for the full ATLS course with certfication. He will be offering a TEAM workshop on Thursday, May 15, at NPACE in Orlando, and is available to teach the course through national or state associations.

Malignant Hyperthermia: The Surgical Team’s Worst Nightmare

By Bob Blumm, MA, RPA-C
President, Association of Plastic Surgery Physician Assistants

At the end of March Stephanie Kuleba, an 18-year-old Florida girl undergoing corrective breast augmentation surgery, died as a result of what doctors are calling a fatal reaction to anesthesia. Hearing about this tragic situation brought back my own memories of a case of malignant hyperthermia (MH), one that had a very different outcome.

Back in the mid-1970s, my supervising physician (SP) and I entered an OR to say hello to a colleague. My SP put his hand on the foot of the patient, who was under anesthesia, and noticed that she felt quite warm. The anesthesiologist asked the circulating nurse to place a rectal thermometer in the patient; it registered a whopping 105 degrees.

The patient’s temperature continued to rise steadily. Steam began to emit from the crystals in the anesthesia canister. What followed next has left an indelible picture in my mind because of the actions of the personnel in the room, the discovery of a wonder drug, and the teamwork that saved this patient from death.

The anesthesiologist recognized the event as a possible MH. Surgery was discontinued and the dressing was put in place. All inhalation drugs were stopped and pure100% oxygen was initiated. A second peripheral line was started and a central line was placed while the nurses gathered ice and packed the patient securely.

Iced saline irrigation was placed down an NG tube, an iced enema was given, and cold IV fluid was administered. The patient’s body temperature continued to rise, and a urinary catheter was placed. My SP got on the phone with his mentor from Johns Hopkins, who recommended that a large bolus of steroid be initiated. The patient’s temperature climbed to 107 degrees.

The anesthesiologist suddenly remembered that a new drug specific for MH had just entered the hospital pharmacy. The medicine, dantrolene sodium, was brought to the OR, where the anesthesiologist began a bolus and then an infusion. The patient’s temperature began to drop steadily.

She was moved from the OR to the PACU and then to the ICU, where 48 hours later she was articulating perfectly and suffering from no ill effects, with the exception of a slight skin slough from one of the IV sites.

I discovered heroes in this scenario—the anesthesiologist who treated the patient, the new wonder drug, dantrolene, and the entire surgical staff consisting of physicians, PAs, nurses, and surgical technologists who worked together to help save this patient. It was an example of teamwork at its finest.

Malignant hyperthermia is an acute, life-threatening pharmacogenic disorder developing during or immediately after a general anesthetic. It can therefore be appreciated or discovered in the OR and the PACU. It is most common in children, teenagers, and young adults, and is usually associated with a history of familial anesthesia problems or fatalities. It can be encountered in dental offices where general anesthesia is employed, the OR, surgicenters, and office-based OR’s—in fact, anywhere where a general anesthetic is given with both volatile gases and depolarizing agents.

For further information on the presentation and the sequela of MH, go to the Web site of the Malignant Hyperthermia Association of the United States, at www.mhaus.org. This site will round out your education and give you the protocols plus a list of supplies needed in a MH crash cart. In an emergency, call the MH Hotline, 1-800-MH-HYPER (1-800-644-9737).