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opioid in anesthesia
If u remember 2 weeks ago, I started presenting some topic in anesthetic and I have been ask to present this lecture (opioid), which come from poppy plant (apian) the natural... Before I start this lecture u should know something about the pathophysiology of pain and why we have some pain killer. As u know, when we defined pain; it’s unpleasant emotionally and sensory felling due to actual or potential tissue damage. if u have pain, whatever the coz of pain, ether it’s trauma (like if I hit u with knife or stick) , chemical , burning or pathology ( like some old people have chronic arthritis (chronic knee pain with limitation of movement )) ,this will initiate mediator at the terminal nerve ending and this will transmit quickly throw dorsal root ganglion to the posterior horn cells in the spinal cord , then spatial canal transmit this pain to the cerebral cortex at high speed ( almost 600 m\sec ) , u know the nerve fiber we have the large A,B, AND C . !!

Why we have to mention the type of nerve fiber? coz for example, morphine it’s good for the visceral pain witch coming from pawl ( visceral) ,but it’s poor as a pain killer for tooth extraction or for bone (here NSAD is superior to morphine in this regard) . So in any clinic when u r going to extract a teeth or something , it’s good to describe a combination (that what we used to do when we were in England) ,, we used to have a model ( don’t leave the patient alone to treat himself by himself) , U are a doctor and u should tell the patient instruction what (he\she) must do ,,and also write it for them (prescription) .

Here is the pain pathway, witch it reach the brain, and here u can manipulated or respond to pain. But how we can block this pain pathway? 1ST We can start with the nerve ending by NSAD, and we can do that if we know the map of the pain. (Here at the nerve ending, the NSAD its number 1) 2ND if u have contraindication ( for NSAD) , like if there is bronchial asthma ,renal damage , heart failure ,Or also in gastric ulcerates (we don’t give them NSA coz they cannot tolerate it and it might coz bleeding) . in this cases we have to give them some simple analgesic like paracetamol (revanin) or as we used to do in England we give them Co-codamol witch is a compound analgesic consisting of a combination of codeine phosphate and paracetamol (60\500 mg ) for each tablet .
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In Jordan we don’t have Co-codamol. In the past we had something like that we called it Revacod, which is a combination of revanin and codeine ,but now it withdrawal from the market because sons of halal didn’t leave anything for sons of halal .{ some good ;) ppl ( zo3ran ) and addicted ppl start 2 attack the markets and pharmacies for this drug coz this drug (codeine) as u know make addiction 2 it}. But from Scientific point view, its number 1 in control the pain. .

‫ مما اضطر‬.. ‫الن اوالد الحالل ماخلوش الوالد الحالل حاجة وصاروا الزعران والمدمنٌن ٌهجموا عالمحالت وٌجمعوا هالدواء‬ ‫السلطات لسحبه من السوق‬
:’( ‫لالسف‬

‫اال بوصفه طبٌة خاصه‬
3rd, thing we can give morphine ether IM or IV, but in IM it has no roll to give morphine in modern anesthetic technique, Y? coz when the patient wake up from surgery after general anesthesia (GA) , he will be in some sort of hypothermic ( there will be some sort of peripheral vasoconstriction in the body ) and the injection will stay in the injection site ,so no systemic absorption will happen and as a result the patient will stay in pain .

We as a human ( Allah crates us in a way that the temp in our body stay the same in winter or summer , from birth to death around 37 c ) unlike us, rats and snake and other ( they sleep for long time in winter coz animal are homo-thermic) not like us, our temp is steady .

But how the body maintain the core temp ( we mean by the core temp ,the temp of the brain ,heart ,kidney and liver ) those are always steady temp , but your hand temp is almost as same as the temp of the surrounding environment .Y? Coz if your hand was hot or 37c then the heat loss is more, so u lose a heat (always). That’s why the ppl who drink alcohol they have falls sensation of worm, why? Coz this protective mechanism we just talk about is not there, so they have wide spired peripheral vasodilatation so they lose heat wail they don’t feel it.

Our target of morphine is in the brain ,so in IM injection the morphine will not reach the target coz of vasoconstriction (after surgery) ,maybe it will reach after 10 hour or more, so the patient in this long time will suffer a lot and long pain and maybe the pain will destroyed him.( ‫ٌعنً ٌهدو االلم‬ ‫وٌتعب‬..)

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So I must give it (morphine) in IV way, and the best IV injection for morphine ((we used to call in England ;) )) PCA; patient control anesthesia, sometimes we don’t have this in Jordan, In PCA we give the patient wrist watch like this ( I think he is showing us his England watch :P on his hand ) and this have 2 limps ,one connected to the drip that contain 50 mg of normal saline in 50 mg of morphine, and the other one connected to the cannula . All u have to do (when u explain this to the patient (the micro operation), press the button here and it will deliver pain killer to u .This is PCA.

Now back to our topic, this is poppy opioid plant

This is the natural plant for all the narcotics, it’s come from here. Country of Afghanistan it has bean 30 -40 years in war and still the money coming between ppl coz they are implanting this and they smuggling it to Europe, this is very expensive when u do it by illegal ways, but in the clinical ground its very cheap, but because of the damaging effect on the ppl and the tendency of tolerance which its the addiction effect of heroin (diamorphine), morphine and cannabis (‫ )حشٌش مخدر‬.So u will be a slave to it. The name "heroin" is only used when being discussed in its illegal form. When it is used in a medical environment, it is referred to as diamorphine Some ppl argue between this and cigarette smoking, and when I asked my friend why u can’t give up smoking he said (he or she coz these days it’s become a kind of Civilization that also the girls do it (smoke or shisha)) They says its addiction, it is NOT, the nicotine is not an addiction but it’s more like habit. But the morphine its strong addiction.

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and the prove for that if u take 2 ppl one is a heavy smoker (10000000 per day) and the other take morphine(addict) and put each one of them in a closed room. The one who smoke he will not do to u anything (maybe) some withdrawal symptoms will come out like anger, break table, But he will not die from smoking for example. The other 1 if u don’t provides him with narcotics for 24 hour or more, withdrawal symptoms will attack him like sweating, pupil dilatation, lacrimation, crying, hypertension, severe abdominal cramps, severe tachycardia and he will die if u don’t give him the dose In rehabilitation central we give him control doses and then Methadone, and then to help him with sociological support for this disaster. The Opioid receptors are predominantly located in the: 1-Brain stem (main target of action and the main site of receptors) we work where? We work in the brain for the opioid receptor. 2-spinal cord (substantia gelatinosa). 3. GIT. We did an extensive study on morphine and we proved that there is a morphine receptor in (all) part of our body

‫ شعروا بان‬.. ‫الدكتور ضرب مثال ع ال العبٌن اللً ٌصٌبهم تمزق فً اربطه الركبة وعطوهم مورفٌن فً الركبه عن طرٌق ابرة‬ ‫ (الجرعه كانت خمسة‬.. ‫االلم خف مقارنة باللً ما اخذوا االبره وهذا ٌدل ع انه فً رٌسٌبتورز فً كل الجسم للمورفٌن‬ )‫ملٌجرام مورفٌن وشوٌة من التخادٌر الموضعٌه‬
This is the: 1.Mu 2. Kappa 3. Sigma receptors, the opioid work on them The morphine is systemic absorption and metabolize in the liver and the site of action we have the brain mainly. And he started talking about how Allah differentiates us from animal that we have brain 2 think with it and use it, we retched the moon…etc. while the animal (even they r stronger than human) stayed in the forest, coz we have a brain that think. َ ‫د‬ َ َ‫{ول‬ ْ‫ق‬ ُ ‫م ْل َنا‬ ًِ‫م ف‬ َ‫ح‬ َ ‫و‬ َ ‫م‬ َ :‫بمٌزة العقل وما ٌمتلكه من قدرات قال تعالى‬،‫مٌز هللا االنسان على سائر المخلوقات األخرى‬ ْ‫ه‬ َ َ‫كرَّ مْ َنا َبنًِ آد‬ َّ ‫ِّن‬ ْ ‫فض‬ ْ‫و‬ ْ. ْ ‫خلَ ْق َنا َت‬ ْ‫ز‬ َ ْ‫ممَّن‬ َ ‫علَى‬ َ‫و‬ َ‫ر‬ ِّ ‫ٌِر‬ ُ ‫َّل َنا‬ ِّ ‫الط‬ 07‫فضِ ٌالً }اإلسراء‬ ِ ‫ٌ َبا‬ َ ‫م‬ َ ‫ت‬ َ ‫ق َناهُم م‬ َ‫و‬ َ ‫ر‬ َ ِّ‫ال َبر‬ ْ‫ه‬ ٍ ‫كث‬ ِ ْ‫ال َبح‬ So when u distract this (brain) by the opioid, even for medical reasons, it will affect their behavior, even the ppl that have a chronic illness for example somebody have terminal cancer he is going to die for sure and the primary lesion were in the liver but after 1 year or more it metastasize and hit the brain, lung and spinal cord, So this person living in intense pain, and they used to call us to
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treat this chronic illness ,so we give them opioid and Fentanyl (without charge ‫ )من غٌر حساب‬coz by this we let them to die in peace and we overlook the said effect coz he is dying for sure. Morphine and Fentanyl patches (fentanyl is 100 time more potent than morphine) we put fentanyl in patches (3-5 microgram)) we do all of this so the patient can’t feel the pain. Large doses of opioid my give nausea, vomiting, histamine release. The morphine is good for visceral pain . Morphine It took its name from the Greek god of dreams Morpheus about 5000 years ago, and still till now it’s the corner stone in the management of pain chronic or acute. (It took its name from the Greek god of dreams Morpheus ) O_o

So we took the natural plant ,which comes from it the codeine and morphine ( both of them r natural ) but other like fentanyl , Sufentanil ( is a powerful synthetic opioid analgesic drug, approximately 5 to 10 times than fentanyl , we use it only for cardiac anesthesia ), pethidine and Remifentanil (ultiva ) , they r more potent than morphine but they r synthetic made by human not fond in nature.

Let’s suppose that morphine given IV or IM , in child its different from extreme age that if someone is 88 or 2 years old the receptors will be very sensitive to morphine ,for example u start in young age then u reach 40 ( the top of your strength ) after 40 the countdown will start till u ْ ِ‫د ع‬ َ ‫ك ْي‬ ً ‫ش ْي‬ َ ‫م‬ َ ِ‫ل‬, ِ‫ع‬ reach the bottom ‫ئا‬ ْ‫ب‬ َ ْ‫م مِن‬ ْ‫ي‬ َ ‫َل‬ َ َ‫عل‬ ٍ‫ل‬ (after 40 years old ,your organ function(brain ,liver, heart ) will be less 1 % every year) that’s y we don’t give the same dose of 88 year old to a 90 years old , respiratory arrest will happen and he will die ( especially if u give it IV ) . ( ‫)هللا الذي خلقكم من ضعف ثم جعل من بعد ضعف قوة ثم جعل من بعد قوة ضعفا‬

The doctor started 2 talk about a serial killer in England , he love to kill old patient by given them high dose of morphine , and he killed over 300 patient ,and they notice that after long time coz nobody thought that they died from high dose ,they thought it was natural death .

So for old ppl or young, we don’t give them the full dose of morphine.

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For the GIT it will reduce the mobility ( maybe constipation will happen ), ppl who is addictive to morphine will have constipation ,pin point pupils , lethargic , slow reaction and heart rate slow also. (When u ask him, what is ur name? after hours he will answer (slow reaction)) Because of easy accesses 2 drugs a lot of ppl die like Michel Jackson ,,( he started 2 talk little pit about how he die ) and also he started 2 talk about CBR and how important it is ,,,etc.

Suppose u want to extract a tooth and u give the patient local anesthesia in the gum and the patient become allergic (it might happen to u even if it’s so rare ) and intra vascular injection happened ,there will be signs for that ( local anesthesia toxicity) , the 1st sign numbness around the lips ,the good doctor will stop administration the remaining of the drug, if u didn’t notes this sign and the patient get in cardiac arrest, so u have to do BLS (basic life support) u can’t wait for the ambulance to come u must do something coz the brain can tolerate up to 3 min without O2 then the damage will start and its irreversible damage . The 1st sign numbness around the lips and then tachycardia then unconscious then cardiac arrest. So u must learn how to do CBR and BLS

‫ الدكتور خرج عن المحاضرة هنا‬:’(
The 1st thing to do whenever there is emergency is :ABC ( airway ,breathing ,circulating in heart ) so u talk to him if he is not responding then shake him gently if still no responding ,check his breathing if there is no breathing then we give him 2 kissing of life ;) So if there is no responding: Close his nose then open his mouth then clear the way if there is something (food, denture. Tongue) then take a big breath then blow up in his mouth (notes: that the head should be extended) ‫عشان التروح النفخة للبطن وٌجب مالحظه عند النفخ ان الصدر ارتفع مش البطن‬ Then u feel the carotid if there is no pulse then make massage for the heart by but your hand together in the lower 1\3 of the sternum ( not on the heart ) do as much as u can and the wrist ,elbow and shoulder should be striate . ( ‫) الى ان ٌفرجها هللا‬ Go back for the record if u want 2 here and learn more about (CBR) and  BLS (basic life support)

‫الدكتور بلش ٌطلع كم شب ع الطاولة وٌشرح طرٌقة التنفس الصناعً وغٌرها بطرٌقة مفصله النها قد تواجهكم فً عٌاداتكم او‬ ‫ جمٌله وفٌها مواقف مضحكة‬.. ‫اذا عندكم وقت اسمعوها‬,,, ‫ وخرج عن الموضوع تبع المحاضرة‬.. ‫حٌاتكم العملٌة او اي مكان‬ ‫ ومفٌدة اٌضا‬.. .. ‫وكٌفٌه اخراجها‬.. ‫وبعدها بلش ٌحكً اذا حدا اختق بتفاحه وعلقت فً حلقه‬

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theater: surgery bed ‫قاعة الجراحه او سرٌر الجراحة‬ The job of anesthesia doctor in my opinion is multifactorial safety valve for the theater, without the anesthetist u will find a lot of dyeing ppl in operation Who decide to do or delay the surgery or if the patient fit for GA (general anesthesia) or not, or the patient is ASA 1 or 2 , or postponed the surgery ? The anesthetist
___________________________________________________________________________ FROM INTERNET … ‫للتوضيح فقط‬ American Society of Anesthesiology patient classification status ASA I Normal healthy Pt ASA II Pt with mild systemic disease; no functional limitation–eg, smoker with well-controlled HTN ASA III Pt with severe systemic disease; definite functional impairment–eg, DM and angina with relatively stable disease, but requiring therapy ASA IV Pt with severe systemic disease that is a constant threat to life–eg, DM + angina + CHF; Pts have dyspnea on mild exertion and chest pain ASA V Unstable moribund Pt who is not expected to survive 24 hours with or without the operation ASA VI Brain-dead Pt whose organs are removed for donation to another E Emergency operation of any type, which is added to any of the 6 above categories, as in ASA II E _____________________________________________________________________________

If we saw that your situation is not good for the operation we will tell the surgeon to stop the surgery, for example: For upper respiratory tract infection 6 weeks. For the stomach 6 hour. If there is Heart failure or diabetic. So put it in the optimal condition
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It’s the primary responsibly of anesthetist, so we give the license to go to the theater or not . Only in life threaten situation like in emergency, if u don’t make the operation he will die, so I do the anesthesia immediately and start the operation. ‫الضرورات تبٌح المحظورات‬

Note: any hospital if u takeout anesthesia department it will just be a big health central, they cannot do anything without u, so u r part of the treatment and part of saving pt. life.

In 3 situation I don’t like to give morphine : 1. In bronchial asthma, coz morphine make releases of histamine (which is a Broncho constriction) as a result there will be problem with breathing. 2. Renal colic, If u have hidden stones and u rush to the hospital coz u have a severe pain (the pain is like if a bullet hit u), so we don’t give morphine for kidney stone coz it will make contraction for ureter so we give them pethidine coz its hypnotic, analgesic, and have a vasodilator effect for the ureter, to reduce the pain.

3. In gallbladder ( ‫ )الحوصلة المرارٌة‬, it’s high in Jordan 2 remove it , coz it is full with stones I don’t know y ,maybe coz of type of food or something , the presentation always female , blonde and 40 , they have high incidence of gallstones . This pain is an early alarm, if there was no pain then u will not know the dangerous, Who is the one that woke up somebody at midnight of chest pain and they discover later its MI? The warning, the pain woke him up. Old ppl and diabetes (long standing diabetes mellitus) neuropathy will come 2 them and the nerve will die mainly the sensory nerve, they die in a good way (painless MI) he go to sleep and never woke up again, no pain or hospital or emergency or Catheter ,,,etc. coz he is gone. so the existing of pain is good its till u that there is something wrong inside your body, if u have a renal stone (I think he meant renal pain),, and u rush 2 the hospital, we will give u a pain killer at first then we do farther investigation we will find for example a renal stone so it should be removed.

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so the exist of painkiller is for a transience effect not long standing effect ,we don’t give u morphine for 30 years ,apart from addiction, it lost the diagnosis. We give u the morphine to easy the pain for u and to find a way to discover what’s going on inside your body. Those the thing we afraid of, also the anaphylactic shock it’s my happen with u anytime anywhere, spatially some of u who want to show them self in front of his family (I’m a doctor) when he have a sister or brother or anyone of the family with tonsillitis and they say Wallah I will cure him in 5 min then they give them IV penicillin or ampicillin, and they don’t know that they have allergic ( anaphylactic) , so in 3 min he will kill them.  Note: it’s not recommended to give any IV injection away from the hospital even in the in hospital it’s the (1:1:30) responsibility of the anesthetist.

That’s why we are so safety here, not like any other hospitals Y? Coz we ask the patient if he have any allergy to penicillin or not. So he say yes or no, and when he say yes, we ask him what happened to u when u had penicillin. ? when I was in England a nurse wrote on a patient charge that he have penicillin allergy ,,and everybody avoid to give him penicillin, but when he came to me, I asked him what happen to u when u had penicillin ? He said my stomach upset!! When I say anaphylactic I mean real symptoms like 1, skin rash 2, difficulty in breathing (bronchospasm) 3, and swelling eyelids. Those the 3 sign if happened, rush them to the hospital if u don’t know the basic rule of CBR, u will lose the patient! So it’s an absolute contraindication if the patient has allergic reaction, it’s as simple as that. As anesthetist ,we r always in arguing with surgeons and the staph, etc. That they tell u, if this patient is allergic to penicillin don’t give it to him, instead give him cefuroxime (3rd generation), I say, but there is 10 % of cross reaction between this and this, what’s the guarantee that this patient is not from this 10 %????? :@ The golden rule ‫اللً طلعت فٌها من خبراتً هنا وفً انجلترا‬ (Whenever u can, avoid the disaster) ‫ابعد عن الشر ٌاعمري وغنٌله‬
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How u can prevent toxicity of local anesthetic, first thing ask him Second thing, weighting of the patient, if we know that the lidocaine or lignocaine {I’m not sure} (the doctor then was cut off and he start talking about some note) ____________________________ [[[[But I think the doctor was going to say that u must know the weight of patient coz the dose will be linked 2 it , so u can avoid toxicity }}}

‫وهللا اعلم‬
Note: if someone have allergy to egg don’t give him Propanol If someone have allergy to kiwi, strawberry, avocado then he have latex allergy. Be careful Coz they will blame u (the anesthetist).

Note: Latex allergy is a medical term encompassing a range of allergic reactions to natural rubber latex and synthetic rubber Some people who have latex allergy may also have an allergic response to any of a number of plant products (kiwi, avocado,,,etc. )

He started to tell a story about women had spinal anesthesia for Caesarean section and she had latex allergy, (in long surgery we but rubber tube throw they urethra for the urine 2 go out) and after 1, 2 hour she had difficulty in breathing, sweating, hypotension, she was lucky that there was an esthetics doctor, he did intubation and save her life.

Back to the point of local anesthetic, u as dentist u give local anesthesia a lot, so u must know the history of the patient and the weighting of the patient coz u give it per k.g The most important when u inject local anesthetic, let’s say this is the gum, don’t inject the syringe but instead of that suck, if there is blood then u r inside a vessel so u pull your hand and re-inject anther place, coz if the local anesthetic access the vessel it will go to the heart and its cardiotoxic to the heart. Marcaine (local anesthetic) it’s potent cardiotoxic, it love and have high affinity to cardiac muscle equal to all resuscitation drugs, if it was immediately resuscitation, u can’t replace the Marcaine on the cardiac and u lose the patient .
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‫لتوضٌح كالم الدكتور ‪..‬انه الماركٌن ٌعشق عضالت القلب وٌرتبط معه بقوة تساوي كل االدوٌة تبع االنعاش فحتى لو‬ ‫حاولنا اننا نعطً ادوٌة لكً تشٌل الماركٌن من القلب لن نستطٌع ذلك وسوف نخسر المرٌض‬ ‫والسبب اننا ما اتبعنا االجراءات الالزمة ‪ 1‬و‪ 2‬و‪ ... 3‬الخ‬ ‫وبعدها تكلم وقال انه الواحد لما ٌتخرج من اي تخصص طبً او غٌره الزم ٌكون ٌعرف قواعد‬ ‫وغٌرها )‪CBR and BLS (basic life support‬‬ ‫وكمل حكً انه فً برطانٌا لما تقدم ع وظٌفه طبٌه بسألوك عن شهادات فً هذه االمور حتى لو انك مخترع اعظم‬ ‫اختراع طبً ‪,‬الزم ٌكون معك هالشهادات واذا ماعندك بحكولك انك مش سٌف دكتور‬ ‫كٌف انت دكتور وماتعرف هاالمور ‪..‬الخ‬
‫‪And he start 2 talk again about fentanyl, Sufentanil and other narcotics that it should be‬‬ ‫‪confined to the anesthetic department (we call them control drugs).‬‬ ‫‪So nobody is allowed to carry needle of fentanyl, even in my pocket (the doctor pocket) u‬‬ ‫‪should not fund this, else u have to tell the Authorities.‬‬ ‫‪This narcotics are given to the patient for specific goal and reason.‬‬

‫واخر شً حكا انه داخل المستشفٌات تجد اطباء وممرضٌن ٌتعاطون هذه االدوٌة المدمنه وانه ٌجب ازالتهم وتنقٌحهم من‬ ‫المجال الطبً ‪ ..‬الخ‬ ‫اتمنى العودة للسالٌدات بعد االنتهاء من المحاضرة‪ ...‬كلها ٌدوب ‪ 14‬سالٌد سهلٌن وماٌاخدوا ‪ 11‬دقاٌق‬ ‫انما الدنٌا فناء لٌس للدنٌا ثبوت‬ ‫‪..‬إنما الدنٌا كبحر ٌحتوي سمكا وحوت‬ ‫‪,,‬ولقد ٌكفٌك منها اٌها الطالب قوت‬ ‫‪..‬ولعمري عن قلٌل كل من فٌها ٌموت‬ ‫‪,,‬فاغتنم وقتك فٌها قبل مافٌها ٌفوت‬ ‫قل بخٌٌر تجتنٌه او تحلى بالسكوت‬

‫‪Done by: ismail al-jawadi‬‬
‫‪Page 12 of 12‬‬

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