Case Study Analysis: Pain Management And Pharmacology

Patient Profile and Medical History

Discuss about the Pharmacogenomics of Pain Management.

The current study focuses upon the case study of Leigh who is 39 year old man and works as an irrigation consultant. He had recently suffered from a car accident when his car operating at high speed had hit the tree. The patient got badly trapped in the car which had to be cut to make his leg free. The man was shifted to the emergency department of the local hospital after the accident. On arrival, Leigh was found in a drowsy and disoriented condition. The upper arm of the patient was swollen and he had difficulty in moving it. The lower leg of the patient was badly lacerated and deformed as it got trapped inside the car. For further diagnosis of the patient, series of X-rays were performed followed by CT scan of head and neck. The patient was diagnosed with left pnemothorax, left humerus, left tibia fibula and small subdural haematoma. It was found that the lower chest was draining small amount of serum fluid whereas the upper chest was intermittently bubbling but not draining effectively. The patient was taken to the emergency theatre for having an ORIF of the lower humerus and ORIF for the lower left leg. The subdural haematoma was effectively managed within the patient. Here, the patient represented slight tingling in his 5^th finger and weakness in both left arm and left leg. The patient had been handed over to another nurse after the CT scan investigations.  The handover nurse had very less knowledge regarding the patient as he was not handling the case from the initial stage. In this respect, a number of medications were prescribed to the patient such as –Metronidazole, cefalothin, fentanyl, paracetamol, ibuprofen, oxycodone. These medicines have been suggested for effective pain management and reducing inflammation within the patient. 

This assignment further discusses the pharmacology related to the case study of the patient. Some of the basic aspects have been discussed such as the pharmacokinetics, phramacodynamics and mode of action of drugs. In order to understand the pain management in the patient, it is important to group the drugs into specific classes and specific action produced by them.

The patient had been provided with variety of pain management drugs. The metronidazole and ceflothin have been prescribed as antibiotics to the patient. On the other hand,  the patient had been suggested fentanyl for pain management. The metronidazole is an antimicrobial used for the treatment of anaerobic and protozoal infections. They are bactericidal in nature and offer prevention by killing the bacterial population. Metronidazole is distributed widely and has low protein binding. The volume of distribution in steady in adults is 0.51 to 1.1 L/kg (sahealth.sa.gov.au 2018). It reaches 60-100% plasma concentrations in most tissues studied.  As suggested by Moulin  et al. (2014), the medicine soon reaches highest concentration in the central nervous system which provides a speedy prophylactic infection and checks the development of infection within the patient. The metronidazole in metabolised in the liver into five metabolites. This could check the progression serious infections as septicaemia   in the patient as the patient   Leigh had severely injured one of his legs from the care metal intrusion. In order to stop secondary infection prophylactic administration was considered over here. As mentioned by Stang  et al. (2014), pharmacokinetics of the medicine is unaffected by chronic renal failure, haemodialysis, pregnancy or enteric diseases. Additionally, the recent phramacodynamic studies have pointed at activity of Metronidazole even 12- 24 hours after administration.

Pharmacology of Pain Management Drugs

The fentanyl had been prescribed as post-operative analgesic to the patient. This is mainly prescribed to the patient for management of acute pain symptoms. Here, the patient Leigh was at the risk of suffering from compartment syndrome. The compartment syndrome is defined as a painful condition which occurs when pressure builds within the muscles (Parker & Rodgers 2015). The syndrome is characterised by swelling or bleeding happens within a compartment. As mentioned by Mazzola  et al. (2014), without a steady supply of oxygen and nutrients the nerve and muscle cells can get damaged. The compartment syndrome could be related to Leigh as he had suffered an injury in his lower leg. Leigh was prescribed a strong analgesic such as fentanyl for controlling the pain owing to fractures and post-surgery (Ting & Schug 2016). The fentanyl is a strong synthetic narcotic with properties similar to morphine. A 0.1 mg dose of fentanyl is approximately equal to 10 mg of morphine. It acts by activating the opioid receptors in the brain which increases the threshold to pain. However as suggested by Gallagher (2018), the prolonged use of fentanyl  have been associated with major complications such as dry mouth, nausea, hallucinations, vomiting, dizziness etc, some of the which have been noticed in the patient.

The fentanyl had been suggested to Leigh as he was experiencing pain due to fracture and surgery. The fentanyl impacts upon both the central and the peripheral nervous system. They act by coupling to G-protein receptors and inhibiting the release of neurotransmitters. They act by modulating the calcium, potassium influx where depolarization of the membrane happens for reducing the sensitivity to pain (Donk et al. 2018).

The other class of pain management medication suggested to Leigh was ibuprofen. It belonged to the class of traditional, non-steroidal anti-inflammatory drug. It exhibits anti-inflammatory and analgesic effects through inhibition of COX pathways (Westdorp et al. 2018). It acts by scavenging the hydroxyl and nitro radicals and inhibits nitric oxide formation through its effects on nitric oxide syntethase forms (MacKenzie et al. 2016).  It may activate the anti-nociceptive axis by binding to the cannabinoid receptors.

The oxycodone is two times more effective compared to morphine. Its effect starts one hour after administration and lasts for 12 hours (Westdorp et al. 2018).  As suggested by Schreiber  et al. (2014), the plasma half-life of the medicine is 3-5 hours and highest concentration is reached within 24 hours. It is metabolised into two ingredients such as oxymorphone and noroxycodone, which are combination of strong and weak analgesic. As suggested by Juul  et al. (2016), long term association is attached with less toxicity compared to other morphine. The medicine reaches the steady state within the patient almost at the same time whether released immediately or in slow doses.

Use of Antibiotics for Secondary Infections

The fentanyl was suggested to the patient as immediate pain management intervention was needed for the patient. This is because the here the patient Leigh was suffering from acute pain owing to fracture and post-surgery. Therefore, fentanyl could be used as an effective pain management strategy with less toxicity and could be easily prescribed to the patient (Peltoniemi et al. 2016).

The cefalothin is suggested to check the development of bacterial infections after surgery, open wound infections. Leigh had been prescribed the medication as he contracted numerous abrasions. Therefore, the patient had chances for the development of respiratory tract disorders and septicaemia. Therefore, prescribing the antiobiotic to the patient could reduce the chances of secondary infections.

The signs and symptoms depicted by the patient over here were mainly   pain, swelling and tingling sensation in the 5^th finger along with weakness in left arm and leg.

 Pain: Here, the patient Leigh had suffered   hematoma in the pnemothorax, humerus , tibia  and fibula.  This could further develop into compartment syndrome in the patient where internal bleeding happens within the compartment resulting in the development of acute pressure on the nerves, capillaries etc. The pain and swelling could be due to compartment syndrome. Hence, immediate pain management therapies were crucial over here such as oxycodone and fentanyl has been suggested as a suitable pain management intervention over here. This is because the oxycodone has been found to have longer affectivity and double the effect of morphine (Ting & Schug 2016). For this class of drugs the effect has been seen to start immediate within an hour of administration and lasts for up to 12 hours. In this respect, the patient had also been suggested fentanyl. However, fentanyl could be associated with a number of contraindications compared to oxycodone (Scholten et al. 2015). For example, prolonged use of fentanyl could results in serious complications within the patient such as withdrawal complications. For example, the fentanyl has been associated with addiction over long term use as they are stronger in effect compared to morphine. In this respect, Leigh had developed severe pneumopthorax hamatoma which could further worsen the respiratory distress within the patient. As suggested by Parker and Rodgers (2015), the administration of fentanyl could be associated with further respiratory complications within the patient. Furthermore the drug has been associated with decreasing the oxygen saturation within the patient. Therefore, post operative monitoring serves as an important credential over here after the administration of the drug. On  monitoring the  condition of the  patient Leigh if its seen that the respiratory rate  falls below 12 breath  per minute it  could  signify  immediate medical attention within the patient.

Effective Pain Management Techniques

Leigh had an open reduction and internal fixation (ORIF). The patient was given antibiotics and anti-protozoal medication such as Metronidazole and Cefazolin to reduce the chances of infection within the patient. Metronidazole has been associated with producing dark colour of urine as the medicine could induce symptoms of dehydration within the patient. The time of administration of the medication should be tightly monitored or regulated within the patient.

For effective pain management within the patient a number of pain management medications could be used such as ibuprofen, oxycodone, etc. Here, the patient Leigh had suffered from a car injury which had immobilised his lower limb and hand.  The patient complained of acute pain owing to compartment syndrome which could be relieved by provision of effective pharmacological medications. For example, the oxycodone has been seen to reduce the pain sensations within the patient by producing a fast effect. Additionally, the strong impact produced by the medicine over long term makes it suitable for using with the patient. In addition, a holistic care regimen could be followed up with the patient such as providing the patient with physiotherapy exercises (sahealth 2018). The physiotherapy exercises could restore the agility and movement patterns within the patient.

Conclusion

The current study focuses upon the aspect of pharmacological pain management for patient who had suffered accident trauma. The patient had been given a mix of prophylactic and analgesics for the management and control of pain within the patient. Some of the prophylactics which had been suggested over here are Metronidazole and Cefazolin. These have been seen to act as antibiotics which will check the further progress of infection within the o patient.  Additionally, the patient had also been suggested with Oxycodone and fentanyl for controlling and tightly regulating the pain within the patient. It has been found that some of the drugs such as oxycodone are best to control the pain within the patient act in a fast manner and have long term effect. Additionally, the contraindications are less compared to other classes of drugs. However, shifting the patient to a more holistic care regimen could help in producing long term effect and provide the patient with more autonomy balancing out the side effects.

References

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