Page 466 Acute Pain Management

Drug Comments Recommendations References
NB doses must still be
titrated to effect for each
patient
Pethidine Norpethidine is the only active Use of alternative agent AMH, 2008
metabolite and is renally recommended Craig & Hunter,
excreted; it is dialyzable 2008
Accumulation of norpethidine Davies et al, 1996
can lead to neuroexcitation Launay‐Vacher et
including seizures al, 2005
Mercadante &
Arcuri, 2004
Simopoulos et al,
2002
Sufentanil Minimally active metabolite No dose adjustment AMH, 2008
required Davis et al, 1988
Murphy, 2005
Tramadol Increased tramadol‐like effects Dose adjustment AMH, 2008
from active metabolite recommended Launay‐Vacher et
O‐desmethyltramadol (M1) Use of alternative agent al, 2005
Tramadol is removed by dialysis recommended with Mercadante &
significant renal Arcuri, 2004
impairment MIMS, 2008
Other drugs
Local There may be no significant Risk of toxicity may be AMH, 2008
anaesthetics difference in plasma affected by abnormalities Crews et al, 2002
concentration of in acid‐base balance De Martin et al,
levobupivacaine, bupivacaine or and/or potassium levels 2006
ropivacaine in patients with Doses may need to be Jokinen, 2005
chronic renal failure unless renal reduced if prolonged or Rice et al, 1991
failure is severe, continuous repeated administration
infusions are used or repeated eg continuous infusions)
doses are used
Increases in free fraction may
result from alterations in protein
binding
CHAPTER 11 concentrations of ropivacaine in
Higher peak plasma
uraemic patients but no
difference in free fraction –
uraemic patients have
significantly higher alpha‐1‐acid
glycoprotein plasma
concentrations
Paracetamol Terminal elimination half‐life may May need to increase AMH, 2008
be prolonged dose interval if renal Craig & Hunter,
Is dialysable impairment is severe 2008
Weak evidence that it Launay‐Vacher et
may increase the rate al, 2005
of progression to
chronic renal failure

418 Acute Pain Management: Scientific Evidence