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Anesthesiology > 11. Pain management > Flashcards

11. Pain management Flashcards

1
Q

Algogenic (pain producing) substances

A
  • K+ from damaged cells
  • Serotonin from active platelets
  • Histamine from mast cells
  • Badikinin from tissue kallikrein
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2
Q

Sensitizing agents in pain

A
  • PGs, LTs from damaged cells

- Primary polymodal afferents: Substance P, Calcitonin Gene Related Peptide (CGRP)

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3
Q

Unimodal receptors

A

Mechanical

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4
Q

Bimodal receptors

A

Mechanical + thermal (> 45 degrees)

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5
Q

Polymodal receptors

A

Mechanical + thermal + chemical

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6
Q

Pain receptor fibres

A

1) Fiber Aδ - fast, sharp pain, easy to localize

2) Fiber C - slow, blunt/burning pain, harder to localize

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7
Q

CNS components of pain

A

Spinothalamic - spinoreticular - spinomesencephalic tracts

  • Complex association between many brain regions*
  • Somatosensory cortex (feeling, localization)
  • Hypothalamus (vegetative, humoral)
  • Limbic (mood, behaviour)
  • Frontal cortex (socialization)
  • Amygdala (cognitive reactions)
  • Hippocampus (pain memory)
  • Ant. Cingular cortex (emotional)
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8
Q

Gate-control theory of pain

A

Ascending inhibitory pathways of brain and ascending Abeta fibers can inhibit spread of incoming pain in SUbstantia Gelatinosa

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9
Q

Opioid and NMDA antagonists action

A

Inhibit inhibitory GABAerg cells which inhibit descending pathways (noradrenaline, serotonin)
Inhibition of inhibition reduces pain sensation

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10
Q

Endogenous opioids

A

Released by stimulation of periaqueductal grey stock (serotonin, noradrenaline)

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11
Q

Pain classifications

A

1) By duration
2) By etiology
3) By associated social/cognitive effects

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12
Q

Pain duration

A

Acute (< 6 weeks/3 months)
- No cognitive-emotional, socializing effects!

Chronic
- Often psychosomatic etc

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13
Q

Nociceptive pain

A

Released mediators activate pain receptors

  • Somatic
  • Visceral
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14
Q

Neuralgia

A

Direct irritation of nerves by mechanic or metabolic disturbance

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15
Q

Deafferentation pain

A

Hyperexcitability of spinal nerves after sensory deafferentation

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16
Q

Special pain syndrome

A

Migraine

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17
Q

Psychosomatic pain

A

Somatic symptoms caused by psychological stress

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18
Q

Afferentation of visceral pain

A
  • Thoracic / abdominal => sympathetic nerves
  • Pelvic viscera => parasympathetic nerves
  • Esophagus, trachea, pharynx => vagus + glossoph. nn
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19
Q

Visceral pain

A
  • Difficult to localize (C fiber)
  • Radiating pain
  • Accompanied by nausea and vegetative signs
  • Can be large pain
  • Reflex contraction of surrounding muscles
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20
Q

Etiology of abdominal pain + quadrants

A

Se internal

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21
Q

Pain radiation visceral pain

A

CNS cannot distinguish between somatic and visceral stimuli, so visceral pain radiates to skin (head zones)
- Dermatoma rule - to same emrbyonic dermatome

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22
Q

Radiation GERD

A

To the back

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23
Q

DDx chest pain that I don’t think of

A
  • Pleuritis sicca
  • Boerhaave SY
  • Tietze SY
  • Herpes zoster
24
Q

IPAT, BPI, McGill questionaire

A

Pain scales:

  • Initial pain assessment tool
  • Brief pain inventory
  • McGill questionaire
25
Pain assessment in ICU
- Behvioural pain scale (BPS) - face, upper limb, ventilation compliance - Critical-care observation tool (CPOT) - face, body, muscle tension, ventilation compliance * The most valid pain assessment tools*
26
WHO guidelines for cancer pain
- Mild pain: NOA (non-opoid analgetics) - Moderate: Low-potential opioids - Strong: High potential opioids
27
Pain management in ICU
- Routinely performed - BPS and CPOT pain assessment - Opioids as first line therapy - Gabapentine or carbamazepine in addition - for neuropathic pain - Thoracic epidural anesthesia in rib fractures
28
Effects of NOA drugs
COX-1 - Kidney function, gastric mucosa - ASA, Indomethacine, Piroxicam COX-2 - Inflammatory augmentation, fever
29
Current first-line NOA drugs
- Ibuprophen, naproxen? - Acetaminophen (paracetamol) - Litterature: diclophenac (MOA)
30
NOA drugs with the best analgetic potential
High - low: 1) ASA, oxicam, acetic acid derivatives 2) Ibuprophen ++ 3) Paracetamol
31
Most immportant SEs of mainetance of opoids
- Obstipation - Sedation - Xerostomia - Pruritus
32
Cannabinoid effects and indications
Effects: antiemetic, analgesic, appetite up, anti-tumorgenetic Indications: Tumor, AIDS, Multiple Sclerosis
33
Peripheral nerve block types + some advantages/disadvantages
Brachial plexus blockade and Femoral blockade Advantages - Less cardiovascular effect - Enhanced bowel motility - No sedation Disadvantages - Needs post-op observation - Needs intra-op supervision
34
Neuroaxial blocks types + some advantages and disadvantages
SPA (spinal) and EDA (epidural) Advantages - Pain stimulus does not enter CNS - no sympathetic stimulation Disadvantages - Parasympathetic tone enhancement - Circulatory and respiratory effects - Delayed mobilization
35
Types of blockade in EDA
- Sensory - Motoric - Vegetative
36
Indications os EDA
- Efficient anesthesia per se (abdominal, special ind: COPD) - Combined anesthesia - Obstetric anesthesia - Permanent anesthesia (acute pancreatitis, cancer?)
37
Absolute CI of EDA
- Hemophilias and/or coagulation disturbances | - Inflammation/wound on skin
38
Relative CI of EDA
- Hypovolemia/shock - Severe cardiovascular disease - Lack of informed consent
39
EDA techniques
1) LOR: Loss of resistance technique - CI: Narrow dura-myelon distance 2) Hanging Drop (hypobaric pressure of epidural space) - Indication: Narrow epidural space
40
Complications of EDA
- Dural punction and Headache (lying position) - Dural punction and myelon punction - Epidural hematome - CNS infection - Cannule disruption - Intrathecal drug misadministration
41
Where to put SPA in adults?
Under L2
42
Effects SPA
- Sensory - Motoric - Vegetative (hypotension, urinary stop)
43
Solution used in SPA
2-4 ml (hyperbaric) bupivacaine 0,5 % solution
44
Complications SPA
- Headache (posture irrelevant) - Infection (sterility) - Backache - Epidural hematome (hemophilias, anticoag, TAG)
45
Local anesthetics
- Weak bases (pH 8-9) | - Less effective in inflammatory environment! (pH decreases)
46
LA - esters
- Cocaine - Benzocaine - Procaine - Chlorprocaine - Tetracaine
47
LA - Amides
- Lidocaine - Mepivacaine - Bupivacaine - Ropivacaine - Articaine
48
Cocaine effects
- Less psychostimulating than amphetamine - Sympathetic effects (vasoconstr, HT, tachyc, mydriasis) - Lethal dose per os 1 g, subcut 0,2-0,4 g
49
Benzocaine
Powder and ointment for painful wounds
50
Procaine
Infiltration anesthesia | - Rapid elimination in liver and by serum esterase
51
Chlorprocaine
Infiltration and regional anesthesia | Twice as effective and less toxic than procaine
52
Tetracaine
Topical anesthesia Ten times more effective, but also more toxic than procaine Accumulates easily in brain (lipid-soluble)
53
Lidocaine
Topical anesthesia Sudden onset and prolonged effect (Dur: 1,5-2 hours) Hypersensitivity common Single max dose ca. 500 mg
54
Mepivacaine
Faster and last longer than lidocaine
55
Bupivacaine
Very effective, but some cardiotoxic - cannot be used i.v!
56
Ropivacaine (S-isomer)
Dissociative anesthesia
57
Articaine
Short-acting, fast metabolism Used in dentistry Used in many ways (iv, spinal, epidural, ocular etc)

Anesthesiology (13 decks)

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