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N928 - Basics of Anesthesia > Acute Postoperative Pain Management > Flashcards

Acute Postoperative Pain Management Flashcards

1
Q

definition of pain

A

an unpleasant sensory and emotional experience associated with actual or potential tissue damage; the 5th vital sign (acc to joint comission)

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2
Q

JCAHO Identified Responsibilities of Pain Management

A
  • patient has right to appropriate assessment and management of pain
  • assess existence of pain, its nature, and intensity
  • record assessment in a way that facilitates reassessment/follow-up
  • assure staff competency in pain assessment and management
  • establish policies that support appropriate prescription of pain medications
  • educate patient/family about pain management
  • address patient needs for symptom management and discharge
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3
Q

nociception

A

detection, transduction and transmission of noxious stimuli

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4
Q

acute pain

A
  • primarily due to nociception
  • short duration (<6 weeks)
  • cause usually known
  • temporary
  • located in area of trauma or damage
  • resolve spontaneously with healing
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5
Q

chronic pain

A
  • may be due to nociception but also affected by psychological/behavioral factors
  • persists beyond normal duration of recovery from acute injury or disease
  • cause may not be identifiable
  • affects patient self image and sense of well-being
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6
Q

thoracotomy incidence of chronic pain

A

5-65%

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7
Q

sternotomy incidence of chronic pain

A

30-55%

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8
Q

mastectomy incidence of chronic pain

A

20-50%

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9
Q

hysterectomy incidence of chronic pain

A

32%

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10
Q

inguinal hernia repair incidence of chronic pain

A

5-35%

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11
Q

four classifications of pain pathophysiology

A
  • nociceptive
  • neuropathic
  • idiopathic
  • psychogenic
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12
Q

nociceptive pain

A
  • appropriate response to identifiable tissue damage
  • due to activation or sensitization of peripheral nociceptors that transduce noxious stimuli
  • pain consistent with degree of tissue injury
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13
Q

neuropathic pain

A
  • may be abnormal, unfamiliar pain, probably caused by dysfunction in the PNS or CNS
  • result of injury or acquired abnormalities of peripheral or central neural structures
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14
Q

idiopathic pain

A
  • pain not attributed to identifiable processes
  • pain in absence of identifiable physical or psychological cause
  • pain perceived to be excessive for the extent of pathology
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15
Q

psychogenic pain

A
  • pain sustained by psychological factors
  • more precisely characterized in psychiatric terminology
  • patients have an effective and behavioral disturbance
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16
Q

4 processes of nociceptive pain

A
  • transduction
  • transmission
  • modulation
  • perception
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17
Q

transduction

A

stimuli translated into electrical energy at the site

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18
Q

transmission

A

propagation of electrical pain impulse through the nervous system

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19
Q

modulation

A

alteration of the stimuli that can be amplified or attenuated

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20
Q

perception

A

based on psychological framework of patient

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21
Q

two subtypes of nociceptive pain

A
  • somatic

- visceral

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22
Q

superficial somatic pain

A

-arises from skin, subQ tissues, and mucous membranes -characterized as well-localized, sharp, pricking, throbbing, or burning

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23
Q

deep somatic pain

A
  • arises from muscles, tendons, joints, or bones

- dull aching that is less well-localized

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24
Q

visceral pain

A
  • due to disease process (appendicitis or pancreatitis) or abnormal function of an internal organ
  • may be localized or referred
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25
Q

two subtypes of neuropathic pain

A
  • central generator

- peripheral generator

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26
Q

central generator

A

central pain due to injury to brain or spinal cord; phantom pain

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27
Q

peripheral generator

A

originates in nerve root, plexus, or nerve; poly-neuropathies or mono-neuropaties

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28
Q

allodynia

A

perception of an ordinarily non-noxious stimulus as pain

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29
Q

analgesia

A

absence of pain perception

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30
Q

anesthesia

A

absence of all sensation

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31
Q

hyperalgesia

A

exaggerated response to noxious stimuli

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32
Q

neuralgia

A

pain in nerve distribution

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33
Q

paresthesia

A

abnormal sensation perceived without stimulus

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34
Q

radiculopathy

A

functional abnormality of one or more nerve roots

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35
Q

how are peripheral nerve afferent fibers categorized

A
  • size
  • degree of myelination
  • speed of conduction
  • distribution of fibers
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36
Q

three groups of peripheral nerve afferent fibers

A
  • Class A (subtypes alpha, beta, delta, gamma)
  • Class B
  • Class C
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37
Q

Class A Fibers

A
  • large, myelinated fibers
  • low threshold for activation
  • 1-20 micrometers in diameter
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38
Q

Class A delta

A
  • mediates pain sensation
  • transmits fast or first pain sensation
  • sharp, stinging, pricking type pain
  • conduction speed of 5-25 m/s
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39
Q

Class A alpha

A
  • transmits motor and proprioceptive impulses

- conduction speed of 60-120 m/s

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40
Q

Class A beta

A
  • cutaneous touch and pressure

- conduction speed of 60-120 m/s

41
Q

Class A gamma

A
  • cutaneous touch and pressure

- conduction speed of 15-35 m/s

42
Q

Class B Fibers

A
  • medium-sized myelinated fibers
  • conduction speed 3-14 m/s
  • diameter less than 3 micrometers
  • higher threshold (i.e., lower excitability) than Class A fibers
  • lower threshold than class C
  • postganglionic sympathetic and visceral afferents
43
Q

Class C Fibers

A
  • unmyelinated or thinly myelinated
  • conduction speed 0.5-2 m/s
  • diameter 0.4-1.2 micrometers
  • preganglionic autonomic fibers and pain fibers
  • slow or second pain
  • burning, persistent, aching, throbbing pain
44
Q

pain conducting fibers

A
  • A-delta fibers

- C fibers

45
Q

A delta fiber pain pathway

A
  • myelinated
  • diameter 1-4 micrometers
  • first or fast pain
  • well localized - sharp, stinging, pricking
  • duration of pain coincides with painful stimulus
  • pain from parietal peritoneum carried here
  • major NT glutamate binds to NMDA and AMPA receptors on postsynaptic membrane
46
Q

C fiber pain pathway

A
  • un-myelinated
  • diameter 0.4-1.2 micrometers
  • second or slow pain
  • diffuse and persistent - aching, burning, throbbing
  • duration exceeds stimulus
  • pain from viscera carried here
  • major NT substance P binds to NK-1 receptors on the postsynaptic membrane
47
Q

pain pathway

A
  • Release of NT/hormones into the blood from the destroyed cell and diffuse to primary afferent neuron (Histamine, Serotonin, Substance P, CGRP)
  • Activate the primary afferent neuron by influx of Na into the cell
  • AP propagated from the site of damage, through the DRG
  • Primary afferent neuron synapses on the interneuron or secondary neuron in the (laminae 1, 2, 5)
  • Secondary afferent neuron decussates to the spinothalamic tract on the dorsal (or posterior) portion of the spinal cord
  • Secondary neuron traverses up the spinothalamic tract to the thalamus of the brain
  • In the thalamus, secondary neuron synapses on tertiary neuron
  • Tertiary neuron brings the afferent information to the somatosensory cortex in the brain
48
Q

substances released from damaged cells that activate pain pathway

A
  • bradykinin
  • cations
  • free radicals
  • histamine
  • prostanoids
  • purines
  • serotonin
  • tachykinins
49
Q

where is pain modulated?

A

descending dorsolateral spinal tract

50
Q

supraspinal analgesia

A
  • refers to the fact that IV opioids act primarily at other sites in the brain including the limbic system, hypothalamus, and thalamus
  • mediated by Mu1 receptors
51
Q

spinal analgesia

A
  • refers to the fact that IV opioids can also produce effects by working in the periventricular area and periaquaductal gray
  • stimulation of Mu2 receptors
52
Q

spinal anesthesia

A
  • neuraxial opioids work at the same receptor site as enkephalin
  • MOA = decrease the release of substance P by binding to Mu2 receptors
53
Q

CV effects of surgical stress response

A
  • HTN
  • tachycardia
  • enhanced myocardial irritability
  • increased SVR (ANG II)
  • CO increase except in patient with compromised LV function
  • increased MVO2 –> ischemia
54
Q

respiratory effects of surgical stress response

A
  • increased in O2 consumption + CO2 production causes increased minute ventilation
  • increased WOB
  • pain may decrease chest expansion (splinting), resultant atelectasis, shunting, hypoxemia, and hypoventilation
  • increase in skeletal muscle tension that results from pain may lead to V/Q mismatch
55
Q

endocrine effects of surgical stress response

A
  • hyperglycemia secondary to increased glucagon + epi and decreased insulin
  • vasoconstriction, increased myocardial contractility, and tachycardia secondary to increased cortisol + catecholamines and activation of RAAS
  • salt and water retention due to increased aldosterone and ADH, may lead to CHF
56
Q

GI effects of surgical stress response

A
  • increased sphincter tone with decreased smooth muscle tone may lead to formation of ileus and lead to PONV
  • decreased oral intake associated with septic complications and delayed wound healing
  • hypersecretion of gastric acid promotes ulcers
  • abdominal distention further aggravates loss of lung volume and pulmonary dysfunction
57
Q

immunological effects of surgical stress response

A

stress response produces leukocytosis with lymphopenia and depresses the reticuloendothelial system predisposing patients to infection

58
Q

hematological effects of surgical stress response

A

increased platelet adhesiveness and diminished fibrinolysis promote a hypercoagulable state; immobility exacerbates this problem

59
Q

general anesthesia influence on surgical stress response

A

not effective in attenuating the response except with high dose narcotic techniques

60
Q

regional anesthesia influence on surgical stress response

A
  • diminishes intensity of afferent impulses getting to spinal cord
  • reduces catecholamine and other stress hormone responses during perioperative period
61
Q

pain assessment

A
  • history of current and persistent pain
  • physical exam
  • pain attributes (intensity, onset, duration, location, descriptors, what exacerbates or relieves pain)
  • behavioral manifestations
  • impact of pain on ADLs
  • current and past treatments
  • are patient’s expectations for pain relief realistic?
62
Q

postoperative pain intensity

A
  • orthopedic/trauma on extremities rated highest
  • also rated among top 25 - appendectomy, cholecystectomy, hemorrhoidectomy, tonsillectomy
  • some laparoscopic procedures ranked unexpectedly high
63
Q

traditional approach to pain mangement

A
  • opioids = mainstay for postoperative analgesia; may be given IV, PO, IM, SubQ, PCA, or neuraxial
  • safe and effective pain control used in treating moderate to severe pain
  • should be administered via most effective route and limiting S/E
64
Q

side effects of opioids

A
  • N/V
  • constipation
  • lethargy
  • sedation
  • respiratory depression
65
Q

Minimum effective analgesic concentration

A

analgesic blood level at which the patient experiences analgesia and the severity of pain rapidly diminishes

66
Q

opioid induced hyperalgesia

A
  • patients receiving opioids exhibit diminished pain threshold and enhanced pain sensitivity
  • escalating opioids worsens pain perception
  • not same thing as tolerance, but the two can happen simultaneously
67
Q

mechanism of opioid induced hyperalgesia

A
  • enhanced release of NT
  • sensitization of primary and secondary afferents
  • upregulation of spinal and supraspinal pathways
  • critical component = activation of excitatory NMDA receptor and central glutamatergic system
  • demonstrated in patients receiving high-dose intraoperative opioids like fentanyl and remifentanil
68
Q

preemptive analgesia

A
  • pain perception can be decrease by using analgesics capable of inhibiting CNS sensitization before pain stimulus occurs
  • drug options = NSAIDs, opioids, LAs, NMDA antagonists, alpha-2 agonists
  • still uncertain/debated
69
Q

multi-modal approach to pain management

A
  • may include more than 1 route of admin
  • use of different agents allows decreased doses of each, thus reduced side effects
  • synergistic effects between drug classes enhances analgesic effects of each drug
  • effective in patients at risk of S/E from large doses of opioids
70
Q

central acting non-opioid analgesics

A
  • clonidine
  • dexmedetomidine
  • gabapentin
  • pregablin
  • ketamine
  • lidocaine
  • magnesium
71
Q

spinal acting non-opioid analgesics

A
  • clonidine
  • dexmedetomidine
  • gabapentin
  • ketamine
  • lidocaine
  • magnesium
72
Q

peripheral acting non-opioid analgesics

A
  • clonidine
  • dexmedetomidine
  • dexamethasone
  • ketamine
  • lidocaine
73
Q

NSAIDs

A
  • effective with mild to moderate pain
  • adverse effects = GI bleeding, ARF, hepatotoxicity
  • avoid in patients with hypersensitivity, significant renal compromise, and PUD
  • use with caution in elderly due to increased risk for renal impairment
74
Q

ketamine

A
  • NMDA receptor antagonist
  • 0.5 mg/kg bolus followed by infusion at 4 mcg/kg/min
  • shown to reduce morphine consumption and pain intensity up to 6 weeks following spine surgery
75
Q

methadone

A
  • D-isomer NMDA receptor antagonist
  • 0.2 mg/kg
  • shown to have a 50% reduction in post-op opioid consumption and pain scores 48 hours after complex spine surgery
76
Q

anticonvulsants

A
  • gabapentin, pregabalin
  • manage spontaneous firing of sensory neurons associated with neuropathic pain (attenuate neuronal sensitization response)
  • reduced incidence of chronic post-op pain syndrome
  • decrease opioid consumption and neuropathic pain 3-6 months following total knee replacement
77
Q

dexmedetomidine

A
  • alpha 2-agonist
  • reduced morphine consumption 2-14 hours post-op; also decreased PONV (most likely to reduced morphine consumption)
  • significantly reduces opioid consumption in obese
  • increased risk of hypotension and bradycardia
78
Q

clonidine

A
  • reduced morphine consumption 12-24 hours post-op; also decreased PONV (most likely to reduced morphine consumption)
  • increased risk of hypotension and bradycardia
79
Q

acetaminophen

A
  • preemptive 15 mg/kg

- MOA unknown

80
Q

Magnesium

A
  • N-methyl-D-aspartate (NMDA) receptor antagonist

- 2 g

81
Q

glucocorticoids

A
  • potent anti-inflammatory agents that play a role in reducing post-op pain
  • also works to manage PONV
82
Q

infiltration of LAs

A
  • may be done by surgeon at beginning or end of case

- ilioinguinal and femoral nerve blocks may be placed by anesthetist

83
Q

regional anesthesia

A
  • preferred to provide postop pain control to a specific part of the body
  • have peripheral and central nerve blocks
84
Q

regional anesthesia advantages

A
  • eliminating need for IV pain medications

- earlier discharge of ambulatory patients

85
Q

regional anesthesia disadvantages

A
  • block failure
  • bleeding
  • hematoma
  • neurological injury
86
Q

peripheral nerve blocks

A
  • lumbar plexus

- interscalene

87
Q

central neuraxial blocks

A
  • spinal

- epidural

88
Q

neuraxial opioids side effects

A
  • itching (most common)
  • nausea
  • urinary retention
  • respiratory depression (early + Late
  • sedation
  • CNS excitation
  • neonatal morbidity
89
Q

respiratory depression with hydrophilic neuraxial opioids

A
  • onset of analgesia slow, duration prolonged
  • intrathecal placement = late respiratory depression (6-12 hours) due to rostral spread; early resp depression does not occur because uptake by systemic circulation is minimal
  • epidural placement = early respiratory depression (within 2 hours) since systemic uptake is greater than with intrathecal placement; late resp depression more likely due to rostral spread in CSF
90
Q

respiratory depression with lipophilic neuraxial opioids

A
  • onset of analgesia is rapid with short duration
  • early resp depression occurs due to significant systemic uptake with both intrathecal and epidural placement; resp depression most pronounced after epidural placement
  • late resp depression does NOT occur because diffusion of lipophilic opioids out of CSF is substantial, therefore rostral spread is minimal
91
Q

alternative approaches

A
  • distraction
  • hyponosis
  • transcutaneous electrical nerve stimulation (TENS)
  • cold
  • heat
  • immobilization
  • positioning
  • exercise
92
Q

distraction

A
  • useful as adjunct
  • music or imagery
  • max benefit if introduced preoperatively
  • requires patient cooperation
93
Q

hypnosis

A
  • state of focused attention combined with decrease in external awareness
  • may not work on all patients
  • social stigma
  • conflicting data on efficacy
94
Q

TENS

A
  • thought to produce analgesia by stimulating large afferent fibers
  • gate theory of pain suggests that the afferent input from large fibers competes with that from smaller pain fibers
  • electrodes applied to same dermatome as pain
  • absence of significant S/E
  • requires professional to instruct in use
95
Q

cold

A
  • alters pain threshold, reduces swelling, and decreases tissue metabolism
  • easy to use
  • contraindicated in patients with decreased circulatory state like Raynaud’s
96
Q

heat

A
  • decreases joint stiffness and increases blood flow

- easy to use

97
Q

immobilization

A

-assists in healing process; i.e. casting

98
Q

positioning

A
  • done Q2H

- improves blood flow and prevents pressure related injuries

99
Q

exercises

A
  • CPM, ambulation, physical therapy

- assists with edema and DVT formation

N928 - Basics of Anesthesia (17 decks)

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