Protocols - Hemorio

CROSS
TOLERANCE
- The subject must be informed in details about the existence of the rescue dose and
that not using it implies necessarily at the worsening of the disease. E.g.: a subject
having 15 mg of Morphine every 4 h requested a rescue drug (10 mg) at 14h, 18h, 2h
and 6h.
- By making the new prescription, we have: 15 mg x 6 = 80 mg + 40 mg of rescue at
24h. A new total of 24 h = 80 + 40 = 130 / 6= 20 mg (approximately), and the new
rescue dose will be 5-20% of the dose from / at 24 h = 120 mg, i.e., of 6-24 mg.
- It is a pharmacological phenomenon, in which a subject that has been treated with a
drug, in this case the opioid, exhibits a physiological resistance to other drug as a result
of a pharmacological similarity between both drugs, i.e., observed in many
pharmacological groups, such as antiviral, antibiotics, analgesic, etc.
6 – ADJUVANT TREATMENT
ADJUVANT DRUGS
Desipramine and Nortriptiline: have less side effects than Amitripline. It is recommended to start the
treatment with the antidepressant at night (because it causes somnolence, which is beneficial to the
subject who has pain and difficult to sleep) with a minimum dose and increases every 7 days, if necessary,
always monitoring the side effects. If it is necessary, old subjects may be used, or those most impaired, to
whom the antidepressant that causes lipothymia must be avoided. The selective inhibitors of the Serotonin
reuptake (Paroxetine, Fluoxetine, Sertraline, etc.) have less side effects, but the value at the treatment of
the pain has barely conclusive studies. They might be used in the morning, to contrapose the sedative
effect of other drugs and to improve the mood. Avoid Fluoxetine in the elderly, because it has a very
extended half-life and it causes lipothymia with hypotension.
CLASS DRUG THERAPEUTIC DOSE ANTAGONIST
ANTICONVULSANT Carmabazepine 400 – 1200 mg/day
Amitripline 25 – 150 mg/day
Imipramine 25 – 200 mg/day
ANTIDEPRESSANT
Nortriptine
Desipramine
50 – 150 mg/day
75 -150 mg/day
Chlorimipramine 50 – 150 mg/day
Fluoxetine 20 – 40 mg/day
NEUROLEPTIC
Chlorpromazine 25 – 200 mg/day
Haloperidol 1 – 5 mg/day
Diazepam
2 – 10 mg/day VO
2 – 5 mg/day EV
- Flumazenil of 0.3 mg EV
every 60 sec, until the
Lorazepan 0.5 – 3 mg/day
reversion of the coma and the
BENZODIAZEPINE
4.5 – 15 mg/day VO breathing depression
Midazolam
0.5 – 2 mg/day EV
1 – 3 mg/day IM
0.5 – 5 mg/h EV continuous
- 0.1 to 0.4 mg/h, in a
continuous infusion
ANTICHOLINERGIC Biperidene
2 – 6 mg/day VO
5 – 10 mg/day parenteral
Promethazine 25 – 75 mg/day
ADJUVANT ANALGESIC DRUGS IN PEDIATRICS
Drug Initial Dose (mg) Maximum Daily Dose
Amitripline 10 3 – 5
Imipramine
Chlorimipramine
10
10
3 - 5
3 - 5
mg/kg/day
Nortriptine 10 1 - 3
Fluoxetine 10 10 – 20 mg/day
Methylphenidate 2.5 05 – 20 mg/dose
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