Acute Pain Flashcards by Linda Chen

list some physical consequences of poor pain management

tachycardia, HPTN, increased cardiac workload, respiratory muscle spasm, atelectasis, hypoxia, post operative ileus, increased risk of oliguria and urinary retention, increased risk of thromboembolism, impaired immune function, muscle weakness and fatigue, anxiety, fear, frustration, poor pt satisfaction

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assessment of acute pain should include

SCHOLAR, inquire about prior workup, diagnostic lab tests, prior self treatment, medical history (including allergies), current medications, physical exam

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acute pain red flags

NIFTI
neurological, inflammatory, fracture, tumor, infection

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nonpharm tx for acute pain is

PRICE
activity as tolerated, physio, external supports, cold/head therapy, massage, support

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how long to rest and ice after an injury?

48hrs

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benefits of nonopioid analgesia

readily available
efficacious
may eliminate need for opioids
may enhance opioid analgesia
varied MOA from opioids

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what does the analgesic ladder say to use for mild pain

nonopioid +/- adjuvant therapy

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what does the analgesic ladder say to use for mild-mod pain

weak opioid (codeine) +/- nonopioid +/- adjuvant therapy

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what does the analgesic ladder say to use for severe pain

strong opioid +/- nonopioid +/- adjuvant therapy

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acetaminophen CI and interactions

ethanol
warfarin (increased INR)
phenytoin
isoniazid

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what is one function of NSAIDs that acetaminophen doesn’t have

antiinflammatory

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NSAIDs are __ effective and ____ toxic than tylenol

more
more

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COX1 inhibition prevents

production of protective mucosal prostaglandins

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T or F: COX2i may still block COX1 at clinically used doses, but lower risk of GI bleeds compared to nonselective (still higher than placebo)

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what NSAID should you use if you have CV concerns?

naproxen

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T or F: ibuprofen is the worst for all cause mortality

F- all NSAIDs about the same

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what 2 NSAIDs should be used if upper GI concerns

celecoxib and diclofenac

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what NSAID should you use if pt has 1-2 GI RF

Celecoxib or nonselective NSAID with GI protection (PPI or misoprostol)

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what NSAID should you use if pt has >2 Gi RF

celecoxib + PPI or misoprostol

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how to prevent NSAID related CV toxicity in chronic use

naproxen preferred
avoid high dose diclo and ibu if on low dose aspirin
caution with other nonselective NSAIDs
avoid COX2 selective NSAIDs

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how to prevent NSAID related toxicity in those with increased renal risk

avoid NSAIDs, use tylenol

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___ causes steric hinderance of ASA binding

ibuprofen

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in those with high CV risk, not taking ASA - ____ is associated with a lower CV risk than ibuprofen and lumiracoxib

naproxen

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in those with high CV risk, taking ASA - _____associated with greater CV risk at 1 yr than lumiracoxib and naproxen

ibuprofen

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when should you consider opioid analgesics

when persistent pain despite reasonable trial of nonopioid analgesics mod-severe pain CI to other analgesics benefits > risks

pain adjuvants may include

gabapentinoids skeletal muscle relaxants cannabinoids

how do skeletal muscle relaxants like baclofen, cyclobenzaprine, and methocarbamol work for pain? what duration?

causes CNS sedation, might not actually be muscle relaxation most benefit in first week

is there a role for cannabinoids in acute pain

some, but much- may cause more pain + not v effective

___ is a a common cause of delirium in the ICU

pain

predisposing factors for pain in the ICU

recent acute pain hx of chronic pain, arthritis, fibromyalgia, traumatic injuries thermal injuries post op surgical site pain infection or malignancy causing inflammation

precipitating factors for pain in the ICU

device placement repositioning diagnostic procedures dressing changes mobilization, physio ET suctioning prolonged immobility

prolonged immobility is a ____ factor

precipitating

traumatic injuries is a ______ factor

predisposing

validated ICU pain assessment scales are shown to (5 things)

improve pain management decrease use of sedatives decrase length of ventilation and ICU stay decrease mortality decrease use of opioids in noncommunicative pts

what opioid is a safer option in renal dysfunction and causes less histamine release

hydromorphone

which opioid needs consideration about renal function

morphine

which opioid has the least hemodynamic effects and histamine release

fentanyl

___ route is most commonly used for opioids in the ICU

why is the PO route not often used for opioids in the ICU

pts often have GI dysfunction resulting in altered absorption

why is the SQ/IM route not often used for opioids in the ICU

altered absorption due to regional hypoperfusion

which opioid is highly lipophilic and can accumulate and cause prolonged sedation

fentanyl

what are some important points for preoperative pt eval

surgery type expected postop pain type, severity, duration past med hx and allergies risk benefit ratio for available techniques pt preference and previous pain experience

what are some persistent post op pain risk factors

severe preop pain repeat surgery high risk of nerve damage severe post op pain

analgesic techniques can be __ or _______

single modality of multimodal (preferred)

postop analgesic strategy may be (4 options)

ATC analgesia for 48-72hrs nonpharm measures nonopioid analgesics (acetaminophen or NSAIDs) opioids (use short acting, oral opioids)

what is PCA

pt controlled analgesia- analgesic admin on pt demand

most common PCA is

IV via an infusion pump

T or F: routine continuous infusion doses are typically not required on top of PCA for opioid naive pts

PCA bolus doses have the following safety mechs build in

fixed bolus dose predefined lockout intervals recording of number of doses used

which maintains more consistent plasma opioid concentrations 1. PCA 2. PRN boluses

PCA

3 points on how to use PCA

educate pt- must understand + willing to use ensure appropriate efficacy and safety parameters adjust as needed for pain score of 1-3/10

when to avoid PCA

not opioid naive or on opioids for chronic pain

what is the only opioid available as injection

ketorolac

which of the following is true about ketorolac (select all that apply) 1. it is the only NSAID available as injection 2. it can be used PO F5D for post op pain and 7 days for MSK 3. it can be used max 2 days IV/IM 4. it has greater analgesic effect to equipotent PO NSAIDs

1,2,3

what is incidental pain

ST pain with predictable cause (bathing, dressing changse, movement)

how to treat incidental pain

avoid precipitating event multidisc approach opioid or other analgesic 30-60min before activity

ketorolac can be used PO for max ___ days for post op pain and __ days for MSK

5, 7

ketorolac can be used IV/IM max ___ days in pts who can not tolerate PO

when can you use acetaminophen in pregnancy

low risk at all stages, routine use not recommended

when can you use NSAIDs in pregnancy

with caution, generally avoid at 20wks, contraindicated in 3rd trimester

why are NSAIDs CI in 3rd trimster

premature closure of ductus arteriosus

what opioids may be taken breastfeeding

morphine, fentanyl, hydromorphone

which opioids should be avoided breastfeeding

meperidine, codeine, oxycodone, hydrocodone

to convert codeine to morphine PO equivalent, multiply by

0.15

to convert oxycodone to morphine PO eq, multiply by

1.5

to convert hydromorphone to morphine PO eq, multiply by

adjuvants to opioids include

gabapentinoids, skeletal muscle relaxants, cannabinoids

what is the least effective option in acute pain 1. fentanyl patch 2. cannabinoids 3. opioids 4. tylenol

T or F: pain in ICUs is a common cause of delirium

T or F: pain in ICUs should be managed after giving sedation

F- manage pain, then give sedation

predisposing factors of pain in ICU

recent acute pain, hx chronic pain, arthritis, fibromyalgia, traumatic injuries, thermal injury, post op surgical site pain, infection or malignancy causing infection

implementation of pain assessment scales is shown to (5 things)

improve pain management, decrease use of sedatives, decrease length of ventilation and ICU stay, decrease mortality, decrease use of opioids in noncommunicative pts

which is safer in renal dysfunction 1. morphine 2. hydromorphone 3. fentanyl 4. codeine

which has the shortest onset and duration 1. morphine 2. hydromorphone 3. fentanyl 4. codeine

3: onset <2min, duration 1-2hrs

which has the least histamine release 1. morphine 2. hydromorphone 3. fentanyl 4. codeine

why is the IV route most commonly used for opioid admin in ICU pts

PO- pts often have GI dysfunction, leading to altered absorption SQ/IM- may have altered absorption due to regional hypoperfusion

________ is highly lipophilic and can accumulate and cause prolonged sedation

fentanyl

what is prefered for analgesics 1. single modality 2. mutlimodal

2- use of =>2 drugs with variable MOA associated with superior pain relief and decreased opioid use

what is a general postop analgesia strategy

ATC analgesics for 48-72hrs nonpharm measures nonopioid analgesics + consider gabapentinoids opioids- short activg, oral

if parenteral opioids are required for more than a few hours, consider ______ instead of PRN intermittent boluses

PCA

which of the following is false about PCA 1. has predefined doses and lockout intervals 2. is better at maintaining constant plasma opioid concentrations compared to conventional IM breakthrough doses 3. allows individualization of dose 4. routine continuous infusion is not required in addition to PCA in opioid naive patients 5. should not be used for patients that are opioid naive

5- should not be used on those that are NOT opioid naive

5- shou;d not be used on opioid naive

when to avoid PCA

not opioid naive or on opioids for chronic pain

what is the only NSAID available as an injection

ketorolac

ketorolax PO max ____ days for post op pain and ____ days for MSK

5 days for post op 7 days for MSK

ketorolac IV/ IM max ___ days in pts who can not tolerate PO

2 days

what is incidental pain

short term pain with predictable cause

how to treat incidental pain

opioid or other analgesics 30-60min before activity