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specialities > Anaesthetics: Essential Pain Management > Flashcards

Anaesthetics: Essential Pain Management Flashcards

1
Q

What is pain?

A

an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage

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2
Q

What are the physical benefits for the patient if we treat pain?

A
  • improved sleep
  • better appetite
  • fewer medical complications (e.g. heart attack, pneumonia)
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3
Q

What are the psychological benefits for the patient if we treat pain?

A
  • reduced suffering

- less depression, anxiety

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4
Q

What are the benefits for the family if we treat pain?

A
  • improved functioning as a family member (e.g. as a father or mother)
  • able to keep working
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5
Q

What are the benefits for society if we treat pain?

A
  • lower health costs (e.g. hospital stay)

- able to contribute to the community

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6
Q

How can pain be classified?

A

duration: acute or chronic
cause: cancer or non-cancer
mechanism: nociceptive or neuropathic

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7
Q

What is acute pain?

A

pain of recent onset and probable limited duration

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8
Q

What is chronic pain?

A
  • pain lasting for more than 3 months
  • pain lasting after normal healing
  • often no identifiable cause
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9
Q

Describe pain from cancer vs non cancer

A

cancer: progressive, a mixture of acute and chronic

non cancer: acute or chronic

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10
Q

Describe nociceptive vs neuropathic pain

A

nociceptive: sharp +/- dull, well localised
neuropathic: burning, shooting +/- numbness, pins and needles, not well localised

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11
Q

when does nociceptive & neuropathic pain occur?

A

nociceptive: obvious tissue injury or illness
neuropathic: nervous system damage or abnormality

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12
Q

What does nociceptive pain function as?

A

protective function

also referred to as inflammatory pain

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13
Q

What are the 4 steps in the physiology of pain?

A
  • periphery
  • spinal cord
  • brain
  • modulation
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14
Q

What physiology occurs in the periphery during the pain response?

A
  • tissue injury
  • release of chemicals e.g. prostaglandins, substance P
  • stimulation of pain receptors (nociceptors)
  • signal travels in Aδ or C nerve to spinal cord
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15
Q

What physiology occurs in the spinal cord during the pain response?

A
  • dorsal horn is the first relay station
  • Aδ or C nerve synapses (connects) with second nerve
  • second nerve travels up opposite side of spinal cord
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16
Q

What physiology occurs in the brain during the pain response?

A
  • thalamus is the second relay station
  • connections to many parts of the brain: cortex, limbic system and brainstem
  • pain perception occurs in the cortex
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17
Q

What physiology occurs during modulation in the pain response?

A
  • descending pathway from brain to dorsal horn

- usually decreases pain signal

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18
Q

What is the gate theory?

A

stimulation by non-noxious input is able to suppress pain by closing the ‘gate’ to painful input preventing pain sensation from travelling to the cortex

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19
Q

Give examples of neuropathic pain

A
  • nerve trauma, diabetic pain (damage)

- fibromyalgia, chronic tension headache (dysfunction)

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20
Q

What is the pathology behind neuropathic pain?

A
  • increased receptor numbers
  • abnormal sensitisation of nerves (peripheral and central)
  • chemical changes in the dorsal horn
  • loss of normal inhibitory modulation
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21
Q

What types of drugs can be used for the treatment of pain?

A
  • simple analgesics
  • opioids
  • other analgesics
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22
Q

Give examples of simple analgesics.

A
  • paracetamol (acetaminophen)

- non-steroidal anti-inflammatory drugs (diclofenac, ibuprofen)

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23
Q

Give examples of opioid drugs

A

weak: codeine, dihydrocodeine, tramadol
strong: morphine, oxycodone, fentanyl

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24
Q

Other than simple analgesics and opioids, what other drugs can be used for pain?

A
  • tramadol (mixed opiate and 5HT/NA reuptake inhibitor)
  • antidepressants (e.g. amitriptyline, duloxetine)
  • anticonvulsants (e.g. gabapentin)
  • ketamine (NMDA receptor antagonist)
  • local anaesthetics
  • topical agents (e.g. Capsaicin)
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25
Q

What non-drug treatments can be used to act at the periphery?

A
  • rest
  • ice
  • compression
  • elevation
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26
Q

What drugs can be used to act at the periphery?

A
  • NSAIDs

- local anaesthetics

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27
Q

What non-drug treatments can be used to act at the spinal cord?

A
  • acupuncture
  • massage
  • TENS
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28
Q

What drugs can be used to act at the spinal cord?

A
  • local anaesthetics
  • opioids
  • ketamine
29
Q

What non-drug treatment can be used to act at the brain?

A

psychological therapies

30
Q

What drugs can be used to act on the brain?

A
  • paracetamol
  • opioids
  • amitriptyline
  • clonidine
31
Q

What route of drug delivery is preferred?

A

Oral

32
Q

What are the advantages of paracetamol?

A
  • cheap, safe

- can be given orally, rectally or intravenously

33
Q

What is the disadvantage of paracetamol?

A

liver damage in overdose

34
Q

What is paracetamol good for?

A

mild pain (by itself) or moderate- severe pain (with other drugs)

35
Q

Give examples of NSAIDs

A
  • aspirin
  • ibuprofen
  • diclofenac
36
Q

What are the advantages of NSAIDs?

A
  • cheap

- generally safe

37
Q

What is the disadvantage of NSAIDs?

A
  • GI and renal side effects

- sensitive for asthmatics

38
Q

What are NSAIDs good for?

A

nociceptive pain

best given regularly with paracetamol (synergism)

39
Q

What are the advantages of codeine?

A
  • cheap

- safe

40
Q

What is codeine good for?

A

mild to moderate acute nociceptive pain

41
Q

What are the disadvantages of codeine?

A
  • can cause constipation

- not good for chronic pain

42
Q

What is tramadol?

A

painkiller with a weak opioid effect plus inhibitor of serotonin and noradrenaline reuptake (modulation)

43
Q

What are the advantages of tramadol?

A
  • less respiratory depression
  • can be used with opioids and simple analgesics
  • less constipating than other opioids
44
Q

What are the disadvantages of tramadol?

A

nausea and vomiting

45
Q

What are the advantages of morphine?

A
  • cheap, generally safe
  • can be given IV, IM, SC, intrathecally
  • effective if given regularly
46
Q

What is morphine good for?

A
  • moderate to severe nociceptive pain (i.e. post-op pain)
  • chronic cancer pain
    not advised for neuropathic pain
47
Q

What are the disadvantages of morphine?

A
  • constipation
  • respiratory depression in high dose
  • avoidance due to fear of addiction
  • controlled drug
48
Q

How does the oral dose of morphine differ from the IV/IM/SC dose?

A

oral dose needs to be increased if changing from IV/ IM or S/C routes as third pass metabolism reduces the amount of morphine available

49
Q

What is amitriptyline?

A

tricyclic antidepressant

50
Q

How does amitriptyline work?

A

increases descending inhibitory signals

51
Q

What are the advantages of amitriptyline?

A
  • cheap, safe in low dose
  • good for neuropathic pain
  • also treats depression and poor sleep
52
Q

What are the disadvantages of amitriptyline?

A

anti-cholinergic side effects (i.e. glaucoma, urinary retention)

long term use might be linked with cognitive decline and dementia

53
Q

Give examples of anticonvulsants that can be used for pain.

A
  • carbamazepine (tegretol)
  • sodium valproate (epilim)
  • gabapentin (neurotonin)
54
Q

Why are anticonvulsants also known as membrane stabilisers?

A

reduce abnormal firing of nerves

55
Q

What are anticonvulsants good for?

A

neuropathic pain

56
Q

How should neuropathic pain be managed?

A

Use alternative analgesics and/or psychological and non-drug treatments

57
Q

What are the steps in the WHO pain ladder?

A

Step 1
- paracetamol +/- NSAIDs

Step 2
- paracetamol (+/- NSAIDs) + Codeine/alternative

Step 3
- paracetamol (+/-NSAID) + Morphine

58
Q

How should the pain ladder be used for mild pain?

A

start at bottom of the pain ladder

59
Q

How should the pain ladder be used for moderate pain?

A

bottom of pain ladder plus the middle ring

60
Q

How should the pain ladder be used for sever pain?

A
  • bottom of pain ladder plus top of ladder; miss out the middle
  • okay to start at the top of the ladder for severe/unbearable pain
61
Q

How should the pain ladder be used as pain resolves?

A
  • move from top to middle of WHO ladder
  • continue bottom rung drugs at all times
  • lastly stop NSAIDs, then paracetamol as more adverse side effects with NSAIDs
62
Q

What is the RAT approach?

A
  • recognise
  • assess
  • treat
63
Q

How do you recognise that a patient is in pain?

A

does the patient have pain?

  • ask
  • look (frowning, moving easily, sweating?)

do other people know the patient has pain?

  • other health workers
  • patient’s family
64
Q

How do you assess a patient’s pain?

A

severity

  • pain score at rest
  • with movement

how does the pain affect the patient?

  • can the patient move, cough?
  • can the patient work?

what is the pain type
- nociceptive or neuropathic

65
Q

What neuropathic features may pain have?

A
  • burning or shooting pain
  • phantom limb pain
  • other features (pins and needles, numbness)
66
Q

What other factors can influence the severity of a patient’s pain?

A

Physical factors
- other illnesses

Psychological and social factors

  • anger, anxiety, depression
  • lack of social support
67
Q

What drugs are used in neuropathic pain?

A
  • amitriptyline
  • gabapentin
  • duloxetine
68
Q

What should be done after using the RAT algorithm?

A

Reassess the patient to see if the treatment is working and if any other treatments are required

69
Q

What is RICE?

A
  • Rest
  • Ice
  • Compression
  • Elevation

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